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Viral Hepatitis Clinical Research Program
University of New South Wales
Infectious Diseases Physician
St Vincent's Hospital
Gregory Dore, MBBS, PhD, FRACP, MPH, has no relevant conflicts of interest to report.
Among people with substance use disorder, people who inject drugs (PWID) are at greatly increased risk of acquiring hepatitis C virus (HCV) infection, with anti-HCV antibody prevalence in this group estimated to be more than 60% in most countries. In fact, injection drug use is the main risk factor for HCV infection in high-income countries and many low- and middle-income countries. A robust, nonjudgmental harm-reduction approach (combining needle/syringe provision and opioid substitution therapy) clearly is integral to an overall strategy for reducing HCV transmission that includes social supports and access to HCV treatment.
Increased Stigma During the COVID-19 Pandemic
The enormous public health challenges presented by the COVID-19 pandemic only have reinforced the underserved nature of society’s most vulnerable populations. People with substance use disorder already are marginalized in society, primarily because of stigma based on illicit drug use and dependency. With hospitals strained to capacity during the COVID-19 pandemic, this stigma places them at increased risk of being deprioritized when presenting to healthcare facilities with symptoms of COVID-19. In addition, this population is more vulnerable to poorer COVID-19 outcomes. Compounding these risks are physical-distancing and lockdown measures, which only increase the social isolation of PWID.
Positive Impacts of the Pandemic
Is there any good news? A few positives have emerged during the pandemic, particularly in relation to the delivery of medications for opioid use disorder (MOUD). In Australia, enhanced flexibility has been a feature, including increased provision of takeaway methadone and buprenorphine doses and less-intensive MOUD monitoring. Depot buprenorphine also has joined the MOUD landscape, providing an option that does not require daily face-to-face encounters, with the added benefit of protection against stigma or loss of privacy associated with attending treatment programs. These new directions must be continued to enable a more patient-centered and less punitive framework for MOUD.
Increasing DAA Treatment Uptake in PWID
In relation to HCV management, ultimately what is required is a commitment to individualized care for PWID—one that is flexible, that is built on a trusting provider–patient relationship, and that delivers improved quality of life and reduced transmission risk. Despite the lack of an effective vaccine against HCV, the advent of direct-acting antiviral (DAA) therapy continues to empower providers and their patients through its incredible curative capacity: Most persons with chronic HCV infection can be cured with 8-12 weeks of DAA therapy. Unfortunately, DAA treatment uptake remains low worldwide, particularly among PWID. A recent analysis of the global cascade of care for chronic HCV infection reported DAA treatment uptake among PWID of 37% in Australia and 13% in the United States. So, what can be done to increase treatment uptake during the pandemic?
Telehealth has provided the opportunity to continue HCV treatment despite physical distancing restrictions and has the potential to improve treatment uptake rates by reducing barriers to care such as travel to in-person appointments. Evidence that limited clinic-based monitoring is required for DAA therapy adherence and response should be harnessed and supported through involvement of peer-based workers. We need to take advantage of the opportunities afforded by the pairing of telehealth with highly effective, safe DAAs to move the agenda for HCV elimination forward.
Expanding Point-of-Care Testing
Lastly, point-of-care HCV antibody and RNA testing is a development that deserves widespread adoption. Screening for HIV, hepatitis B, and HCV through just a finger prick of blood should become the new normal in the coming years. Now that we have pangenotypic anti-HCV regimens, the simple presence of active HCV infection, rather than the viral load and genotype, should be the only marker for consideration of treatment initiation.
How can simplified HCV screening, treatment, and monitoring be incorporated into management for underserved populations? Are there any real contraindications to DAA therapy to consider for a person who is currently injecting drugs? Can HCV treatment and MOUD be used as prevention tools? Answer the polling question and join the conversation by posting in the discussion section.