Hepatitis C care located within a needle and syringe
programme in New York achieved a three times higher cure rate than referral to
a patient navigator and linkage to medical care at a harm reduction programme
or clinic, a randomised trial in New York City has found.
Improving the uptake of hepatitis C care among people who
inject drugs is essential for achieving the elimination of hepatitis C,
especially in countries where the majority of people with hepatitis C are
current drug users.
People who inject drugs experience numerous barriers to care.
As well as dealing with competing priorities including food, housing, addiction
and criminalisation, people who inject drugs also face barriers to obtaining care
due to stigma and requirements for abstinence from drugs before initiating
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
Although drugs services may offer hepatitis C testing, people
who are diagnosed with hepatitis C are usually referred to other services for
treatment. As a consequence, linkage to care is often sub-optimal.
Offering care in services with low barriers to entry, where service
users can walk in without an appointment and also obtain methadone maintenance,
has been shown to encourage the uptake of treatment.
The study, carried out at the Lower East Side Harm Reduction
Center in Manhattan, was designed to test whether offering hepatitis C
treatment through a ‘low threshold’ drugs service resulted in better cure rates
than linking people to existing hepatitis C care in medical facilities.
People were eligible to join the study if they had injected
drugs for at least one year, had injected drugs within the previous 90 days and
had a detectable hepatitis C viral load. The study excluded people already
engaged in hepatitis C care, people with decompensated cirrhosis or liver
cancer, and pregnant women.
The study recruited 167 people with hepatitis C between 2017
and 2020 and randomised them to receive hepatitis C care at Lower East Side
Harm Reduction Center or referred them to a standard-care arm in which a treatment
navigator supported them to obtain care through clinical services in New York
The study population had a median age of 42 years, just over
three-quarters (77%) were male, 58% were Hispanic and 32% were White. Seven
per cent were living with HIV. Thirty per cent were not receiving opioid substitution
treatment, 64% received methadone and 6% received buprenorphine.
Consistent with the proportion not receiving opioid substitution
treatment, 39% reported daily injecting during the previous month. Forty-seven
per cent were injecting heroin, 27% cocaine and 24% were injecting cocaine and
heroin together (a speedball). Eighty per cent had visited a needle and syringe programme
during the past 90 days.
The majority received treatment with glecapravir/pibrentasvir
(Maviret) (71%). Twelve per cent received sofosbuvir/velpatasvir (Epclusa),
8% received grazoprevir/elbasvir (Zepatier), 5% received sofosbuvir/ledipasvir
(Harvoni) and 3% received sofosbuvir/velpatasvir/voxilaprevir (Vosevi).
People in the accessible-care arm were significantly more
likely to achieve a sustained virological response (cure) than people in the standard-care arm (67% vs 22%), due to a much higher rate of linkage to care. People in
the accessible-care arm were more likely to be referred to a hepatitis C
clinician (92% vs 44%), more likely to attend the first clinical visit (86% vs
37%), to complete baseline laboratory testing (86% vs 31%) and start treatment
(78% vs 26%).
The rate of cure in the accessible-treatment arm was not
affected by age, sex, ethnicity, homelessness, daily injecting or prior
hepatitis C treatment. The rate of treatment failure did not differ
significantly between the two study arms (10% vs 9%).
The study investigators point out that the cure rate was
roughly three times higher in the accessible-care arm despite the fact that people
in the standard-care arm had the support of a patient navigator who could accompany
them to clinic visits, work to resolve insurance issues and support adherence.
The rate of cure in the standard-care arm was higher than in programmes for
people with inject drugs outside New York City that lack a patient navigator.
The investigators were surprised to learn that being a
previous user of the needle and syringe programme did not affect whether people
in the accessible-care arm started treatment or not. Only 30% of participants
in the accessible-care arm were recruited at the study site; the remainder were
recruited at other needle and syringe programmes or through study participants
They say that providing a low-threshold non-judgemental
environment for people to encounter hepatitis C testing and treatment may be
more important than providing a familiar environment.
They also point out that 70% of participants were already
receiving opioid substitution treatment but had not yet been cured for
hepatitis C, suggesting a failure to engage opioid substitution treatment recipients in hepatitis C care.