Offering hepatitis C treatment and opioid substitution
therapy with buprenorphine at the same location can help increase adherence and
reduce harms associated with injection drug use, according to findings from the
ANCHOR study presented at the 2018 International
Liver Congress in Paris.
Hepatitis C virus (HCV) is easily transmitted through shared syringes
and other drug injection equipment, and current and former injection drug users
have high rates of infection.
Many providers have traditionally considered people who inject drugs to be poor candidates for hepatitis C treatment. What's more, ongoing
injection drug use can result in HCV re-infection after being cured. The availability of highly effective and well-tolerated direct-acting
antivirals (DAAs) that can cure most people in 8 to 12 weeks leaves little
justification for withholding treatment from this highly affected population.
In fact, providing hepatitis C treatment may offer an opportunity to help
people address their drug use.
Elana Rosenthal of the University
of Maryland School of Medicine presented results from ANCHOR, a study of
hepatitis C treatment for people who inject drugs conducted at an urban harm reduction centre in Washington,
DC. The centre employs community health workers and provides transportation as
The study enrolled 90
participants with an opioid use disorder who had injected opioids within the
past 3 months and had not been previously treated with DAAs.
About three-quarters were
men, more than 90% were black and the median age was 56 years; a quarter had
compensated liver cirrhosis. Less than 5% had HIV co-infection. Sixty per cent
said they injected opioids at least once a day, and more than a quarter
reported receptive sharing of injection equipment (meaning someone else used it
first). Around 80% were enrolled in syringe exchange programmes. Half reported
unstable housing and more than 90% had a history of incarceration.
hepatitis C treatment using sofosbuvir/velpatasvir (Epclusa), a one-pill, once-daily regimen that is effective against
all genotypes of HCV. They received a month's worth of pills at baseline and at
weeks 4 and 8, with end-of-treatment follow-up at week 12 and post-treatment
follow-up at week 24; follow-up will continue through week 96 to assess
While undergoing hepatitis C
therapy, participants were offered the opportunity to start medication-assisted
treatment for addiction using buprenorphine, a partial opioid agonist that relieves
withdrawal symptoms and reduces drug cravings. Sofosbuvir/velpatasvir and
buprenorphine were given at the same location by the same medical provider.
About a third (30%) were
already on opioid substitution therapy at screening. All of the rest expressed
an interest in buprenorphine and 39 people (43%) started using it; 22 (24%) did
not use any medication-assisted treatment. (Those who switched from methadone
to buprenorphine were not included in this analysis.)
At the time of the analysis,
55 participants had reached 24 weeks of post-treatment follow-up. Among the 46
people with available viral load data, 91% achieved sustained virological
response, or continued undetectable HCV RNA (SVR24), which is considered a
cure. Looking at all 55 people, 76% achieved SVR24, 13% missed the study visit,
7% still had detectable HCV, 2% had died and 2% were still awaiting results.
People who were either on
opioid substitution therapy at baseline or who started buprenorphine were significantly
more likely to attend clinic visits than those not on any medication-assisted
treatment. Attendance at week 4 was 95%, 89% and 71%, respectively. Attendance
was lowest at week 12 (86%, 81% and 40%, respectively), but increased again by
week 24 (88%, 86% and 67%).
Participants who were still
on buprenorphine at week 4 were more likely to receive their second bottle of sofosbuvir/velpatasvir
than those who were never or no longer on opioid substitution therapy (100% vs
82%). At 8 weeks, 96% of those who were on opioid substitution therapy at
baseline, 90% of those who started buprenorphine and 87% who were not on medication-assisted
treatment picked up their third bottle of sofosbuvir/velpatasvir.
Participants who started
buprenorphine during hepatitis C treatment showed a significant decline in
behaviours associated with HIV and HCV transmission risk from baseline to week
4, week 12 and week 24. No significant change was observed for people who were
already on opioid substitution therapy at baseline. Those who were not on any medication-assisted
treatment also saw a decline, but this did not reach statistical significance.
"Preliminary results of
the ANCHOR study support that active PWID [people who inject drugs] not on medication-assisted treatment can
be successfully initiated on buprenorphine during the course of HCV treatment,"
the researchers concluded. "HCV treatment may provide a critical opportunity
to not only cure HCV, but simultaneously prevent re-infection and treat opioid
use disorder in high-risk, marginalized PWID."