New recommendations on hepatitis C treatment and care for
people who inject drugs encourage physicians to offer treatment to all people
who inject drugs diagnosed with HCV, and to offer a comprehensive package of
social support and harm reduction to enable people to adhere to treatment.
The recommendations are published
this month in the International Journal
of Drug Policy.
The publication of the recommendations coincides with an
international meeting in Sydney, Australia, the 4th International Symposium on
Hepatitis in Substance Users (view presentations
here), which focuses on the management of hepatitis among
substance users.
The recommendations were developed by an international
expert panel convened by the International Network for Hepatitis in Substance
Users. The panel included specialists in the treatment of hepatitis C, harm
reduction and the management of addiction, as well as advocates and epidemiologists.
The strength of scientific evidence for each recommendation
is clearly stated, and where recommendations are based on expert consensus in the
light of limited evidence or conflicting findings, this is made clear.
The recommendations are designed to overcome a series of barriers
to HCV treatment for people who inject drugs, in particular the perception that
people who are using drugs cannot adhere to antiviral treatment. The recommendations
state: “A history of IDU and recent drug use at treatment initiation are not
associated with reduced SVR and decisions to treat should be made on a
case-by-case basis“.
The recommendations recognise that for many people who
inject drugs – as well as former injecting drug users – housing, social
support, finances and mental health pose significant barriers to engagement
with medical care and adherence to treatment. Addressing these issues is part
of pre-treatment assessment.
People who inject drugs should be offered HCV treatment “based
on an individualised evaluation of social, lifestyle, and clinical factors” and
because “successful treatment may yield transmission reduction benefits”.
Pre-treatment assessment and education should consist of the
following interventions:
- Pre-therapeutic education should include
discussions of HCV transmission, risk factors for fibrosis progression,
treatment, reinfection risk and harm reduction strategies.
- Pre-therapeutic assessment should include an
evaluation of housing, education, cultural issues, social functioning and
support, finances, nutrition and drug and alcohol use. People who inject drugs should be linked
into social support services, and peer support if available.
- Models of HCV care integrated within addiction
treatment and primary care health centres, as well as prisons, allow successful
pre-therapeutic assessment.
- Peer-driven interventions delivered within OST
settings may lead to higher rates of treatment initiation and should be
offered, if available.
- Care coordination in conjunction with
behavioural interventions can increase likelihood of people who inject drugs being evaluated and
initiating treatment and should be offered, if available.
- Pre-treatment assessment should include an
evaluation of previous or current psychiatric illness, engagement with a drug
and alcohol counsellor or psychiatrist and discussions around potential
treatment options.
- In cases of acute major and uncontrolled
psychiatric disorders, a pre-treatment psychiatric assessment is recommended.
- In case of relevant psychiatric co-morbidities
with an increased risk for interferon-associated psychiatric side effects
interferon-free direct-acting antiviral therapy should be considered.
Although the recommendations note that direct-acting
antiviral regimens still need to be evaluated in people who inject drugs, they
also state that sofosbuvir, sofosbuvir/ledipasvir, paritaprevir/ritonavir/ombitasvir/dasabuvir,
daclatasvir, and simeprevir can be used in people who inject drugs on opioid
substitution therapy. Specific methadone and buprenorphine dose adjustment is
not required when taking direct-acting antivirals, but the panel recommends
that monitoring for signs of opioid toxicity or withdrawal should be undertaken.
Where direct-acting antivirals are not yet available, “PWID
with early liver disease should generally be advised to await access to
interferon-free DAA regimens”, but if direct-acting antivirals are available,
treatment should be offered regardless of liver disease stage, “taking into
account social circumstances, adherence and medical and social comorbidities”.
The recommendations also address the question of
reinfection. A perceived risk of reinfection should not be considered grounds
to deny treatment to people who inject drugs, and people who clear HCV should
receive harm reduction counselling and services, as well as annual HCV RNA
testing, or testing after a high-risk injecting episode.
Hepatitis C treatment should be delivered by a
multidisciplinary team, and access to harm reduction programmes, social work
and social support services should form part of HCV clinical management.
Screening and assessment for HCV should be offered in prisons, along with
antiviral treatment.