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High adherence and hepatitis C cure rates in active drug and alcohol users

Keith Alcorn
04 February 2021
Image: Drew Farwell/Unsplash

People who use drugs achieved high rates of hepatitis C cure on direct-acting antiviral treatment despite ongoing drug and alcohol use, demonstrating that active drug use should not be a barrier to treatment, US researchers report in the journal Open Forum Infectious Diseases.

Active drug and alcohol use have disqualified people with hepatitis C in some settings from obtaining direct-acting antiviral treatment. But there is little evidence to support this barrier.

Researchers at the University of Colorado wanted to see whether various methods of supporting adherence had any greater impact on adherence to direct-acting antiviral treatment in people who were using drugs.

They recruited 60 people with hepatitis C who reported drug or alcohol use within the previous 30 days. The study excluded people previously treated for hepatitis C who had cirrhosis.

All participants received treatment with ledipasvir/sofosbuvir (Harvoni) for 12 weeks.

Participants were randomised to one of two methods of adherence support: either video monitoring of pill taking or using a wireless pillbox (users receive a text message if they don’t open the pocket pill dispenser each day).

The study population was predominantly male (78%), White (72%) and HIV positive (78%). All those with HIV were taking daily HIV medication too. Most participants had genotype 1a (65%) or 1b (22%) infection.

Study participants were asked about drug use at study visits every two weeks and underwent urine testing for drugs.

Drug and alcohol use were common during treatment. Marijuana use was reported at 60% of all participant study visits, methamphetamine at 37% of visits, opioids at 22% of visits and cocaine at 17% of visits. Injecting was reported at 20% of visits, mainly of methamphetamine (78% of injecting). Alcohol use was reported at 56% of visits and 19% reported heavy alcohol use during the preceding two weeks.

Eighty-six per cent of participants who started treatment achieved a cure. Three of eight who were not cured were lost to follow-up, two were dropped from the study for protocol violations and three were virological non-responders or reinfected). Two of the participants lost to follow-up had negative HCV RNA results by week 8, suggesting that they may have been successful responders to treatment despite lack of post-treatment follow-up.

Adherence to study medication was very high; participants took a median of 96% of doses. There was no difference in adherence rates according to reminder method.

Multivariable analysis showed that poor adherence was associated with Black race (odds ratio 4.09 [1.42-11.74, p=0.009), HIV co-infection (OR 2.94 [1.37-6.32], p=0.006), cocaine use (OR 2.12 [95% CI 1.08-4.18], p=0.03) or methamphetamine use (OR 2.51, 95% CI 1.44-4.37, p=0.001).

Although sustained virologic response was achieved by participants with adherence rates as low as 30% in this study, the mean adherence rate in the only case of confirmed virologic failure was 100%, but this participant had cirrhosis.

“Our findings support expanding DAA to treat people who use drugs to eradicate HCV and the use of technology-based measures to facilitate treatment uptake in this population,” the researchers conclude.


Brooks KM et al. Adherence to direct-acting antiviral therapy in people actively using drugs and alcohol: the INCLUD study. Open Forum Infectious Diseases, 19 November 2020.