1 December 2022
From the impact of DAA treatment on quality of life to the question ‘are women being left behind?’, INHSU 2022 shared broad perspectives, insights and research on hepatitis and people who use drugs.
The key themes of reinfection rates, stigma and discrimination and the need for flexible, people-first services became quickly apparent, alongside interventions such as treatment as prevention, point of care testing, and the need to combine harm reduction and HCV services.
HCV elimination among people who inject drugs – where are we now and where to from here?
Natasha Martin, University of California, San Diego, USA
INHSU Vice President Natasha Martin presented empirical real-world data on progress towards elimination targets:
- There is sufficiant evidence that OAT – if delivered at a sufficient dose – prevents HCV transmission by 50%
- Combined OAT and NSP provision reduces HCV transmission by 70%
- Despite this, the global coverage of harm reduction remains very poor, with only five countries providing both OAT and NSP, with those countries only covering 2% of the global population of people who inject drugs
- HCV testing and treatment remain below what is needed for elimination
- There is strong evidence that people who use drugs want to be treated, and DAAs and new novel care pathways show that it is possible
- 10 years of data shows that treatment as prevention can lead to substantial declines in HCV prevalence, even with the risk of reinfection
- HCV treatment plus harm reduction is the best way forward to reducing chronic prevalence
- Theoretical models provide economic arguments for the treatment of people who inject drugs showing that for every person who is treated early, two additional infections could be prevented
- Real-world data from Australia shows HCV treatment rates as a % of those with chronic HCV dropped from 11% (2019) to 9% (2020) and 8% (2021)
- Another study (pre and post-DAA) showed that there is 58% incidence in HCV incidence
- COVID-19 led to some treatment disruptions but provided these disruptions do not continue, targets can still be met
Real-world examples of success in achieving HCV elimination among people who inject drugs
John Dillon, University of Dundee, UK, Sigurdur Olafsson, Landspitali University Hospital, Iceland, Ketevan Stvilia, National Center for Disease Control, Georgia
This session provided three real-world examples of countries making impressive strides towards hepatitis C elimination. There were some core themes and takeaways:
- Even if elimination targets are met, efforts must be maintained — there needs to be a strong focus on prventing and treating reinfection to ensure targets remain on track (in Iceland, the reinfection rate is 15.9%)
- Holistic thinking across the whole care cascade is needed to ensure success — make sure every step is mapped out so that people can be directed clearly and quickly to what is next
- Provide medicines and home services for free to remove barriers and encourage uptake
- Demedicalize diagnosis and make testing simple — it can, and should, be done by anyone including peers
Changes in self-reported quality of life associated with successful DAA Hepatitis C treatment in people who use drugs
Scott McDonald, Glasgow Caledonian University, UK
Chronic HCV infection has a detrimental impact on health-related quality of life, and the introduction of highly-effective interferon-free direct-acting antiviral (DAA) therapy has spurred the scale-up of treatment among people who inject drugs in a number of countries. Scott’s study analysed the impact of the new DAA treatment on quality of life.
Interferon-based treatment was associated with worsened quality of life during treatment. Evidence from a large population-based survey indicates that while successful antiviral treatment via DAAs does not lead to a durable improvement in quality of life, it does demonstrate a transient positive impact on quality of life around the time of SVR achievement.
Opportunistic treatment of Hepatitis C infection: A randomized controlled trial of immediate treatment initiation among hospitalized people who inject drugs (Opportuni-C)
Håvard Midgard, Akershus University Hospital, Norway
Hospitalisations for drug-related harms may represent opportunities to engage people who inject drugs in HCV testing and treatment. The trial consisted of a pragmatic, stepped wedge cluster randomised trial recruiting HCV RNA positive individuals admitted for inpatient care in departments of internal medicine, addiction medicine, and psychiatry at three hospitals in Oslo, Norway.
The intervention involved immediate HCV treatment initiation with individualised follow-up. Standard of care was a referral to outpatient care at discharge. A total of 200 participants were enrolled between 1 October 2019 and 31 December 2021.
Treatment completion within 6 months was accomplished by 67 of 98 (68.4%) during intervention conditions and by 36 of 102 (35.3%) during control conditions. Adjusted for secular trends and cluster effects, the intervention was superior to standard of care in terms of treatment completion (aOR 4.8; 95% CI 1.8-12.8; p=0.002) and time to treatment initiation (aHR 3.5; 95% CI 2.3-5.3; p<0.001). The model of care should be considered for broader implementation to reach the World Health Organization HCV elimination targets.
Recruitment and Treatment of Social-Injecting Networks in the Treatment and Prevention Study: A Real-World Social Network Design Community-Based Trial of Direct-Acting Antivirals for Hepatitis C Among People Who Inject Drugs
Brendan Harney, Burnet Institute, Australia
Brendan presented an analysis that builds on two decades of research on hepatitis C among social networks of people who inject drugs, and examines factors associated with the recruitment of ‘secondary participants’ into HCV testing and treatment (these were people who had recently injected with a primary participant and who were subsequently nominated by that person).
The analysis found that secondary participants recruited early were very close to primary participants, whereas people recruited later were not as close, and also were more likely to have been incarcerated in the prior 12 months.
Overall, this provides interesting insights to think about how network-based models of care might be designed and implemented going forward, and suggests people may be willing to refer their close contacts early in their treatment journey and to refer other peers once they have developed a trusting relationship with the treating clinician or service.
Changing Trends in Hepatitis C Reinfection Rates Following the Scale-Up of Direct-Acting Antivirals Among People Who Inject Drugs in Scotland
Norah Palmateer, Glasgow Caledonian University, UK
There has been rapid scale-up of DAAs in Scotland among PWID, particularly in the Tayside region. This has resulted in major reductions in population level prevalence of HCV infection among PWID.
This study looked at how has the scale up of DAAs and associated changes in HCV prevalence affected HCV reinfection rates among PWID. The cohort in the study were PWID on the Scottish HCV Clinical Database who had achieved an SVR after treatment. The study found that:
- Reinfection increased in the early phase of treatment scale up with DAAs among people who use drugs
- Rates may have peaked in the areas of Scotland with the greatest scale up of DAAs and substantial reductions in HCV prevalence
- But, estimates of HCV reinfection remain uncertain due to limited regular re-testing post SVR among PWID, especially during the pandemic
- Efforts to scale up testing in PWID who have achieved SVR – enabling prompt diagnosis of reinfection and retreatment – are crucial, alongside high harm reduction coverage
A novel Hepatitis C intervention in Denmark to test and treat people who inject drugs
Anne Overhus, Odense University Hospital, Denmark
In the context of the Danish epidemic, elimination efforts should be directed towards people who inject drugs and this presentation focused on a peer led program by Brugernes Akademi.
- This peer led model of screening involved a hepatitis C antibody test carried out in a mobile unit, followed by a fingerstick test if the result was returned positive
- Peer support was provided and referral to fast-track clinic for evaluation
- 1,013 individuals were screened, 114 returned with a positive RNA test, 80 initiated treatment and 76 completed treatment
- 88% male and the medium age was 46.5
- Peers would organise the service, engage people at risk, provide patient support, educate volunteers, and advocacy. 74.1% received peer support for treatment
- Being an undocumented migrant was a major cause for not accessing care, which poses a challenge for HCV elimination in Denmark due to the risk of onward transmission
- In conclusion, a peer-led point of care service is a model that can reach and treat the most marginalised patient group
Two randomized controlled trials to measure the impact of HCV self-testing in key populations in Georgia and Malaysia
Sonjelle Shilton, FIND, Switzerland
The presentation began with some important points about self-testing to contextualise. The first being that antibody testing is not here to replace other testing modalities and the second being that it is not a definitive test but rather a first step towards learning a hepatitis C status. In July 2021, WHO issued its first recommendation on self-testing.
- The objective of this program was to assess the impact of HCV self-testing home delivery on uptake of HCV antibody testing
- Interested candidates could complete a short online questionnaire for eligibility. If eligible, individuals were directed to complete an online consent form before being randomised to intervention or control
- Participants were surveyed on demographics, knowledge, attitudes and practices at baseline and then 1 to 4 weeks after enrollment.
- In terms of uptake, in Malaysia, 98.1% completed HCV self-testing with a blood sample, 98.7% completed HCV self-testing with a saliva sample, and 51% with the control (standard of care)
- In Georgia, 38% surveyed that they had never tested before, and in Malaysia this figure was 58%. This showed an ability to reach new people for testing
- At least 80% said they would like to use a self-test again if they had the kit and instructions
- The study concluded that the evidence suggests HCVST increases uptake of HCV antibody testing and that additional supportive materials may be needed to insure people who inject drugs who use a self-test can interpret the results
Rapid Hepatitis C Treatment Initiation in Young People who Inject Drugs: Final Results From The HCV-Seek, Test & Rapid Treatment (HCV-ST&RT) Randomized Pilot Clinical Trial
Benjamin Eckhardt, NYU School of Medicine/Bellevue Hospital, USA
Benjamin presented final data from the Accessible Care Trial for curing HCV in people who inject drugs. The trial took place at a NYC syringe service program (Accessible Care) with facilitated referral to local providers through a patient navigation program (Usual Care).
In this randomised clinical trial, significantly higher rates of cure were achieved using the accessible care model that focused on low-threshold, colocated, destigmatised, and flexible hepatitis C care compared with a facilitated referral. To achieve hepatitis C elimination, expansion of treatment programs that are specifically geared toward engaging people who inject drugs is paramount.
Are we leaving women who inject drugs behind on the ‘road to hepatitis C elimination’? A qualitative exploration to minimise inequalities in health
Alison Marshall, The Kirby Institute, UNSW Sydney, Australia
Recent evidence has indicated that women who inject drugs are less likely to initiate hepatitis C virus (HCV) treatment than men who inject drugs. On the ‘road to HCV elimination’, concerted efforts are needed to minimise inequalities in care.
Alison (see research profile here) provided an overview of qualitative findings from the ETHOS Engage cohort (Australia).
- Women participants narrated incidents of ‘double stigma’ when receiving HCV care, i.e., perceived to be judged more harshly by health services due to their gender and injection drug use.
- When HCV care and gender-based care overlapped (e.g., prenatal care), participants were mostly dissatisfied with the care received and/or expected to be reprimanded based on past stigmatising experiences.