Alcohol use among patients with hepatitis C (HCV) and HIV coinfection using drugs was frequent and often not detected via self-report, according to data published in the Journal of Viral Hepatitis. However, when measured objectively, heavy alcohol use was not associated with failure to initiate HCV treatment or achieving cure.
Before the advent of direct-acting antiviral (DAA) treatment, alcohol cessation was commonly required before the initiation of HCV treatment as a result of concerns regarding alcohol’s effect on immune responses and the effectiveness and adherence to interferon treatment. Current HCV guidelines from the American Association for the Study of Liver Diseases/Infectious Disease Society of America prioritize treatment with DAAs for all individuals, including those with heavy alcohol use; this change was attributed to the fact that DAA treatments regimens are short, nontoxic, highly effective, and present the potential for cure. However, alcohol cessation often continued to be mandated by clinicians before DAA treatment, as a result of ongoing concerns regarding treatment adherence and effectiveness.
The Chronic Hepatitis C Management to Improve Outcomes (CHAMPS) study is a 3-group randomized controlled trial that is evaluating contingent cash incentives and peer mentors compared with usual care on HCV treatment uptake and sustained virologic response. The primary outcome of this study was the initiation of DAA treatment within 8 weeks of enrolment (12 weeks if a change in HIV regimen was required).
A total of 144 patients with HCV/HIV coinfection who use drugs were recruited and randomly assigned to 1 of 3 treatment groups. To investigate the effect of alcohol use on the HCV care continuum among this population, the 10-item Alcohol Use Disorders Identification Test (AUDIT, hazardous: male ≥8, female ≥4) and the alcohol biomarker phosphatidylethanol (PEth; heavy: ≥50 ng/mL) were employed to assess alcohol use.
Hazardous drinking was reported on AUDIT by 28% of study participants, and 35% had heavy use according to PEth. The median ages of the 135 participants with PEth data was 55 years, 59% were male, 92% were black, 91% reported a drug use history, and 97% were receiving antiretrovirals. Among the 47 individuals with PEth scores ≥50 ng/mL, 49% reported no or minimal alcohol on AUDIT.
Treatment for HCV was initiated in 103 of 135 patients, of whom 92% achieved sustained virologic response. PEth results of ≥50 ng/mL were not significantly associated with failure to initiate HCV treatment (relative risk, 0.72; 95% CI, 0.35-1.48) or failure to achieve cure (relative risk, 0.85; 95% CI, 0.46-1.57).
Because this study was based in a clinic, it may not fully apply to community settings, where the first barrier to care is making it to a clinic. A second study limitation was that each received treatment adherence support based on evaluations by their clinician, meaning clinical sites would need to develop protocols to ensure patients received the required support. Furthermore, investigators stressed the need to document these findings in real-world settings, as the data collected here were within the context of a randomized controlled trial, wherein most participants received some intervention.
The investigators concluded that, “in the era of DAAs, individuals with alcohol use including those with heavy alcohol use are able to initiate HCV treatment and achieve cure.”
Curative HCV treatment could then offer a reduction in morbidity and mortality in these individuals who are at high risk for liver fibrosis, cirrhosis, and death. Investigators also hoped that this and similar work continues to open up access to DAAs to those with alcohol use, in part because HCV treatment offers a chance to engage patients in alcohol counseling before, during, and after treatment.
Irvin R, Chander G, Ward KM, et al. Unreported alcohol use was common but did not impact hepatitis C cure in HIV-infected persons who use drugs [published online December 18 2019]. J Viral Hepat. doi:10.1111/jvh.13251