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Division of Infectious Diseases
Johns Hopkins University School of Medicine
Division of Infectious Diseases
Johns Hopkins Hospital
Oluwaseun Falade-Nwulia, MBBS, MPH, has disclosed that she has received consultant/advisor/speaker fees from Gilead Sciences and funds for research support from AbbVie.
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It is estimated that more than 2 out of 3 new hepatitis C virus (HCV) infections in the United States are attributable to injection drug use. Early detection and treatment of HCV among people who inject drugs (PWID) not only preserves the health of the individual, but also provides an opportunity to break the transmission cycle by treating an HCV-infected individual before he or she transmits to others. Although it is exciting that currently available oral direct-acting antivirals are highly effective and lead to HCV cure in the majority of PWID who initiate these treatments, HCV treatment initiation among PWID remains low at <20%.
Why HCV Services Are Needed in Addiction Treatment Settings
Addiction treatment settings routinely provide services to PWID, and many patients access care at these settings multiple times a week. They are a trusted source of care provision, and many of their staff members—including counselors or peer recovery specialists—have a lived experience of substance use. The integration of HCV services into the addiction treatment setting seems like a logical one, especially when considering approaches for addressing the multilevel barriers to HCV treatment. Such barriers include the following:
In this context, it is important to remember that HCV is a disease that disproportionately harms the health of people who use drugs. Although there are many infections that fall into this category, HCV stands out as being the deadliest infectious disease in the United States while also being an infection that is easily curable with just 8-12 weeks of daily pills.
In our approach to increasing HCV screening and treatment among PWID, we must work with voices trusted by PWID in settings such as addiction medicine sites to ease access. A key component of this approach is ensuring that staff and providers in these settings are knowledgeable about HCV, including the potential for significant morbidity and mortality and the risk of transmission to others that is preventable through curative treatment.
At a minimum, HCV testing should be routinely available in addiction medicine settings. This approach is consistent with best practice guidelines for opioid treatment programs developed by the Substance Abuse and Mental Health Services Administration that recommend HIV and viral hepatitis testing as components of ongoing client evaluation.
How to Integrate HCV Services in Addiction Treatment Settings
Some addiction medicine settings have phlebotomy on-site and can set up the transportation of blood samples to local commercial laboratories for HCV antibody testing with reflex to HCV RNA testing and insurance billing.
Other addiction medicine settings choose to partner with health departments, academic centers, or industry partners to implement regular hepatitis C testing events, with careful attention to linkage to HCV treatment for those found to have HCV infection. Peer or other patient navigation strategies have been found to be effective in increasing linkage to treatment.
The safety, tolerability, and simplicity of oral HCV direct-acting antiviral administration make it possible to implement HCV treatment in addiction medicine settings. Models and programs such as the ECHO learning collaborative model and remote consultation are effective for supporting HCV treatment by nonspecialist providers in a wide range of settings. Other addiction medicine settings may choose to partner with off-site specialists who treat patients on-site via telemedicine. To be sustainable, systems to support and reimburse addiction medicine settings for provision of HCV care will be required.
Whatever approach is chosen, as a community invested in advancing health equity for PWID, it behooves us to leverage the unique opportunity that addiction medicine settings provide for stigma-free HCV care at locations that PWID routinely access and in which they feel comfortable and safe.
Do you have experience providing HCV services either directly at, or in collaboration with, addiction medicine or harm reduction clinics? What aspect of the implementation process have you found the most challenging? What tips do you have that may be helpful to others seeking to provide HCV services or connect services to addiction medicine settings? Please join the conversation and share your experiences in the comments box.
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