Professor of Medicine
University of South Carolina School of Medicine - Greenville
Vice Chair of Academics and Research
Addiction Resource Center
Greenville, South Carolina
Alain H. Litwin, MD, has disclosed that he has served on advisory boards for AbbVie, Gilead Sciences, and Merck and has received funds for research support from Gilead Sciences and Merck.
It is now clear that HCV treatment in the form of direct-acting antivirals is effective in achieving high rates of sustained virologic response (SVR) among persons who inject drugs (PWID), and guidelines have been revised to recommend that HCV treatment be considered for each person, regardless of drug use. PWID comprise most of the new and existing HCV infections globally and in the United States. This provides a huge opportunity to progress our efforts in HCV elimination, as expanding treatment uptake and cure in this population would greatly decrease the disease burden. However, many barriers in the United States result in poor linkage to HCV for PWID. Barriers related to the healthcare system include lack of insurance coverage for treatment in PWID, lack of access to care in rural settings, and remaining practitioner concerns regarding PWID candidacy for treatment, adherence ability, and reinfection risk. In addition, patient barriers include lack of HCV knowledge, fear of treatment adverse events, and stigma and discomfort encountered in the healthcare system. How can we overcome these barriers and improve linkage to HCV care and treatment for PWID?
Treating Drug Use Disorder Can Enhance Linkage to HCV Care
Although there is still some reluctance among providers to treat drug use disorders, data suggest that integrated care aimed at treating the whole person, including providing treatment for drug use disorders, can improve linkage to HCV care among PWID. Norton and colleagues conducted a retrospective study to identify factors associated with HCV care milestones in patients who initiated buprenorphine treatment at a primary care facility in the Bronx, New York, between 2009 and 2014. The study found that patients who were retained in buprenorphine treatment for opioid use disorder were more likely to be referred to specialty HCV care and to initiate HCV therapy vs patients who were not retained in buprenorphine treatment.
These data highlight an important aspect of HCV treatment in PWID: Providers should treat the whole individual, including addiction care and mental health care, to successfully treat HCV. Unfortunately, many clinicians, particularly in the primary care setting, do not prescribe medications for addiction treatment, despite their demonstrated efficacy and an ongoing opioid epidemic in the United States. Therefore, further education and training of healthcare providers on addiction and addiction treatments is necessary to more successfully battle the HCV epidemic.
Models of HCV Treatment in PWID
Several studies suggest that colocalized care models, in which HCV treatment is provided alongside and at the same location as treatment for substance use disorder and/or other comorbidities, are the most effective approach to HCV care for PWID. This can include HCV treatment in primary addiction care centers or by general/primary care practitioners who have undergone training in both addiction and HCV service provision. Telemedicine can be employed to train and support general practitioners in HCV and addiction care.
Models are also being assessed that include specific approaches to improve adherence and treatment outcomes. In the PREVAIL study, 150 PWID receiving treatment at a methadone clinic were randomized to receive HCV treatment either individually, as part of a peer group that met weekly (group meeting with providers for physical exams, psychosocial support, education, adverse event management), or via directly observed therapy (DOT). The study demonstrated that all 3 models of care were effective, with high SVR rates across all groups (90% individual, 94% group, 98% DOT). Other studies have also demonstrated high cure rates in patients receiving opioid agonist therapy (OAT), but it remains to be seen if a larger study may show significantly improved SVR rates with intensified models of care such as DOT and how these different models may work for individuals not enrolled in OAT programs and/or with ongoing injection drug use. The HERO study may help answer some of these questions. This larger study is comparing HCV treatment outcomes among individuals with ongoing injection drug use who are randomized to receive HCV treatment by DOT (in person or by self-captured video submitted daily) or through trained staff who provide patient support (patient navigators) at 8 different sites throughout the United States. This study has completed enrollment (N ~ 750), and results are expected later this year or in early 2020.
Looking Beyond HCV
Many successful models of care for HCV, drug use disorder, and other health issues experienced by PWID emphasize the importance of peer support. These models adhere to the “nothing about us without us” movement incorporating peers to provide input, reduce stigma and discomfort, and potentially help patients overcome competing life priorities. Organizations such as FAVOR Greenville in South Carolina (www.favorgreenville.org) offer recovery coaching to help individuals navigate substance use disorders and can be an essential resource to link patients to HCV care and other critical services. Given the high SVR rates demonstrated for PWID who undergo HCV treatment, it is possible that this population does not necessarily need intensified models of care and that standard HCV treatment models may be enough.
Although minimal care models are interesting as the field moves toward a simplified approach to HCV treatment, there may be some risks to minimizing HCV interventions for PWID. Models of care that incorporate addiction treatment, peer support, and other services tailored to PWID may be beneficial in linking patients to care that goes beyond HCV treatment. If minimized, we may miss the opportunity to link PWID to treatment options for drug use disorder, mental health care, and tobacco cessation support. In addition, we may lose patients with advanced fibrosis to follow-up, impeding provision of recommended periodic screening for liver cancer. Overall, it is important to consider the whole person and the complex medical needs that an individual PWID may have when assessing models of HCV care. If we elevate and support our patients to reduce and ultimately eliminate stigma and remember the importance of overall health, we may begin to close multiple treatment gaps for this underserved population, including HCV treatment.
What are your thoughts about HCV treatment models for PWID? Do you have concerns about prescribing HCV treatment for PWID? Please join the conversation and share your experiences in the comments box below.