The World Health Organization’s global strategy on viral hepatitis aims to reduce new infections by 90% by 2030.1 To meet that goal, increased effort is needed to engage people who inject drugs (PWID). Although the estimated prevalence of hepatitis C virus (HCV) in this population is 50%, HCV treatment uptake is low despite high treatment willingness and comparable treatment outcomes between PWID and the general population.
“This is concerning, as lack of access to treatment among PWID may lead to a massive untreated and viremic population at risk of progressing to end-stage-liver disease, increasing the burden on the healthcare system, as well as furthering HCV transmission,” according to a 2018 paper published in the International Journal of Drug Policy.1
Numerous studies have demonstrated the benefits of integrated care to address both infectious diseases and substance use disorders in this group.2-4 Compared with more formal treatment settings such as specialist clinics and hospitals, the “integrated, community-based addiction treatment and care models may provide easier access to care and may improve HCV treatment uptake.”
There is an opportunity to improve HCV treatment rates for PWID by integrating direct-acting antiviral (DAA) therapy into current models of community-based addiction. In a study at a center in England that integrated HCV care into a substance abuse treatment setting, 69% of participants were drug users and 47% had mental illness.3 Of the 87 patients who initiated treatment, 98% complied with treatment and 87% achieved a sustained virologic response.
Other findings support the potential benefits of integrated opioid agonist therapy and HCV care models led by community pharmacists, with increased screening, follow-up, and treatment compliance.5 “Ultimately, the redesign of addiction treatment programs to address HCV should consider the overall health of PWID to reduce harms and prevent HCV infection and reinfection,” wrote authors of recent article.1 “Key access points where PWID frequent which integrate HCV care and prevent leakage from the cascade of care with point-of-care diagnostics and treatment, such as in community pharmacies, addiction treatment support groups, and needle distribution programs, should be explored.”
In moving toward integrated delivery of HCV care within addiction treatment settings, several challenges warrant attention. For example, the simplicity of DAA therapies presents the opportunity for physicians other than hepatologists — such as addiction medicine specialists — to treat HCV infection. It is unclear whether these providers are willing to assume this role and whether hepatologists will be agreeable to this scenario. However, a 2017 study found similar outcomes (in terms of sustained virologic response) among people who were HCV positive and were receiving DAA therapy from nurse practitioners, primary care physicians, and specialists, highlighting the feasibility and value of expanding the range of providers delivering HCV care.6
In addition, there is a need to ensure availability of treatment for other substance use disorders in addition to opioid use disorder. There is scant evidence regarding therapies for people with HCV who only use stimulant drugs, although stimulant use among PWID is increasing.
Another challenge to be addressed is the “outdated and restrictive drug policies have prevented patient access to harm reduction and addiction services in many settings,” such as criminalization of drug use and denial of treatment for active drug use, as stated in the recent paper.1 “Political will and multi-stakeholder engagement is required to alter the narrative regarding illicit drug use and to remove these restrictions.”
To further discuss integrated care for HCV and addiction, Infectious Disease Advisor interviewed Lianping Ti, PhD, assistant professor of medicine at the University of British Columbia, and research scientist in Epidemiology and Population Health at the BC Centre for Excellence in HIV/AIDS.
Infectious Disease Advisor: What are some of the benefits of integrated HCV and addiction care, and how common are such programs currently?
Dr Ti: We know from recent literature that there are huge benefits to integrating HCV services within addiction care, which include high HCV treatment initiation, retention, and completion rates. In the DAA era, where treatment options are shorter, safer, and more effective than previous medications, there are an increasing number of clinical programs that have sought to integrate HCV services within addiction treatment and care.
A number of different models of care exist, including holistic team-based models, and nurse-led and pharmacy-led models. The optimal model will likely depend on the setting and available resources.
Infectious Disease Advisor: What are some of the challenges involved in integrating care, and how might these be addressed?
Dr Ti: As therapeutic demand increases, there will be a need to shift treatment and care to other physicians — such as addiction medicine specialists and general practitioners — to deal with a system strained by a paucity of hepatologists. Despite the documented benefits of nonspecialists treating HCV, it is unclear whether these physicians are willing to take on a new area of work and whether hepatologists will readily hand over prescribing responsibility that has predominantly been in their control.
Continued dialogue in academic and clinical forums will be needed to tease apart physician roles and responsibilities as more patients are becoming eligible for HCV treatment.
Infectious Disease Advisor: What should be next steps in this area in terms of research or otherwise?
Dr Ti: Most research to date has focused on integration care models that generally serve a population of opioid users. Given that there are a large proportion of polysubstance use and stimulant users among people who inject drugs, an area of future research focus would be the development of pharmacotherapeutic options to treat stimulant use disorders and to examine its impact on HCV treatment outcomes.
- Bird K, Socías ME, Ti L. Integrating hepatitis C and addiction care for people who inject drugs in the era of direct-acting antiviral therapy. Int J Drug Policy. 2018;59:1-2.
- Bajis S, Dore GJ, Hajarizadeh B, Cunningham EB, Maher L, Grebely J. Interventions to enhance testing, linkage to care and treatment uptake for hepatitis C virus infection among people who inject drugs: a systematic review. Int J Drug Policy. 2017;47:34-46.
- Hashim A, O’Sullivan M, Williams H, Verma S. Developing a community HCV service: Project ITTREAT (integrated community-based test – stage – TREAT) service for people who inject drugs. Prim Health Care Res Dev. 2018;19(2):110-120.
- Wolfe D, Luhmann N, Harris M, et al. Human rights and access to hepatitis C treatment for people who inject drugs. Int J Drug Policy. 2015;26(11):1072-1080.
- Radley A, Tait J, Dillon JF. DOT-C: a cluster randomised feasibility trial evaluating directly observed anti-HCV therapy in a population receiving opioid substitute therapy from community pharmacy. Int J Drug Pol. 2017;47:126-136.
- Kattakuzhy S, Gross C, Emmanuel B, et al; the ASCEND Providers. Expansion of treatment for hepatitis C virus infection by task shifting to community-based nonspecialist providers: a nonrandomized clinical trial. Ann Intern Med. 2017;167(5):311-318.