DAA treatment highly effective for people who use drugs

Direct-acting antiviral (DAA) treatment is highly effective at curing hepatitis C in people who inject drugs and in people receiving opioid substitution therapy (OST), a systematic review and meta-analysis of 38 studies published in The Lancet Gastroenterology and Hepatology shows. Experts from Australia’s leading hepatitis C research centre say that the findings of the review demonstrate that policies that deny hepatitis C treatment for people who use drugs are unacceptable.

The findings were published to coincide with the 7th International Symposium on Hepatitis Care in Substance Users, which took place last week in Portugal.

Despite a recommendation from the World Health Organization that people who use drugs should receive DAA treatment for hepatitis C, some countries do not provide treatment to active drug users and physicians often cite concern about adherence as a reason to deny treatment to active drug users.

The meta-analysis showed a sustained virologic response (SVR) rate of 87.7% in recent drug users and an SVR rate of 90.7% in OST recipients. Treatment completion rates were high (97.5% in both recent drug users and OST recipients).

When the analysis was confined to people with recent injecting drug use, rather than all drug use, the SVR rate was 87.4% (treatment completion rate was 96.9%).

"People should not be denied life-saving treatments, simply because of their recent drug use," said Associate Professor Jason Grebely from the Kirby Institute at the University of New South Wales.

"Policies that deny hepatitis C treatment for people who use or inject drugs are unacceptable; they are driven by discrimination as opposed to evidence. I hope our research will encourage countries to overturn these policies and allow treatment to all people living with hepatitis C, regardless of current or previous drug use.”

HCV elimination in people who inject drugs

Achieving the elimination of hepatitis C virus (HCV) in people who inject drugs will require a comprehensive health system-wide strategy that addresses stigma, barriers to care, financing, the involvement of people who inject drugs and devolution of treatment services to community level, according to an expert review published this month in Liver International.

The authors identified actions relating to each of the World Health Organization’s six health system building blocks and highlighted actions relating to communication and participation as essential to the hepatitis C response.

These actions include:

  • Improved communication with people who inject drugs to improve health literacy and raise awareness of the benefits of treatment.
  • Peer-led services to make information relevant and accessible.
  • Involvement of people who use drugs in the design and delivery of services and the development of national strategy.
  • Training for healthcare workers that addresses stigmatising language/terminology, attitudes, practices and policies.
  • Training for healthcare workers on hepatitis C to raise awareness of diagnosis and treatment.
  • Task-shifting, or the devolution of aspects of treatment and care to non-physicians, should be promoted to expand the healthcare workforce capable of diagnosing hepatitis C and initiating people on treatment.
  • Expand the availability of saliva and fingerprick antibody testing to expand the range of venues where screening can be offered.
  • Improved health information systems to monitor uptake of testing and treatment.
  • Developing the financial case for elimination.
  • Leadership to ensure that people who use drugs are meaningfully involved in the development and implementation of national elimination strategies and included in national treatment guidelines.

Little progress towards universal testing of 'baby boomer' generation in United States

The proportion of baby boomers who have been tested for hepatitis C in the United States since 2013 has increased only marginally despite a US Centers for Disease Control and Prevention (CDC) recommendation that everyone born between 1945 and 1965 should be tested for hepatitis C at least once, researchers from Johns Hopkins University report in Clinical Infectious Diseases.

The CDC made its recommendation to screen everyone in the 'baby boomer' generation because studies showed that three out of four people with hepatitis C virus in the US fell into the baby boomer age group.

Among those born between 1945 and 1965, testing coverage increased from 12.3% in 2013 to 17.3% in 2017. Among those born between 1966 and 1994, testing coverage increased from 13.2% to 16.8%.

The authors of the study say that barriers to implementing the screening recommendation include lack of health insurance and lack of screening outside primary care.

Reinfection risk higher in recent drug users

Direct-acting antiviral (DAA) therapy cures at least nine out of ten people with hepatitis C after a course of once-daily treatment lasting 8 to 12 weeks. Reinfection after treatment can occur if people continue to share needles or injecting equipment. Men who have sex with men are also at risk of reinfection if they have unprotected sex.

The risk of reinfection in these groups of people has led some clinicians to question whether active drug users should be treated for hepatitis C while they continue to use drugs.

Canadian researchers investigated the risk of reinfection in people who received DAA treatment in the province of British Columbia. They found that approximately one person in a hundred who had been cured of hepatitis C became reinfected with hepatitis C in each year of follow-up after being cured. Reinfection rates were higher in recent drug users, especially younger drug users, but opioid substitution therapy during or immediately after DAA treatment reduced the risk of reinfection.

The authors point out that, as treatment eligibility expands and the number of younger people with less advanced liver fibrosis are identified for treatment, the proportion of recent and current injectors receiving DAA treatment is likely to rise. Education about reinfection risk, engagement in harm reduction services and provision of opioid agonist therapy need to be provided alongside DAA therapy, the authors recommend.

Screening pregnant women and infants for hepatitis C

Hepatitis C has spread rapidly because of an increase in injecting drug use in the United States over the past decade. Outbreaks of hepatitis C in the states of Indiana and Kentucky have drawn attention to the spread of hepatitis C outside large cities and raised the question of whether pregnant women should be screened for hepatitis C.

A 2017 study by the US Centers for Disease Control and Prevention estimated that between 1.25 and 1.63% of pregnant women were hepatitis C virus (HCV) antibody positive in the United States. The study concluded that around 29,000 women with HCV gave birth each year and 1700 infants had HCV infection.

A Viewpoint article published by hepatitis C specialists from several of the largest medical schools in the United States says that changes in the epidemiology of hepatitis C over the past decade make it essential to switch to a policy of universal screening in pregnant women.

They argue that too many cases of hepatitis C are being missed because healthcare providers fail to ask about potential risk factors and pregnant women may not wish to disclose information about drug use.

But pregnancy provides an important opportunity to diagnose hepatitis C and engage women and their partners in care, and also to prevent hepatitis C transmission to the unborn child.

The experts draw attention to the lack of direct-acting antivirals currently licensed for use in pregnant women but say that until universal screening uncovers the true extent of HCV infection in pregnant women, “pharmaceutical companies will not consider this population for therapy.”

As well as screening pregnant women, more attention needs to be paid to screening the infants of women with hepatitis C, another US study shows. The study looked at HCV antibody testing in pregnant women receiving treatment for opioid use disorder, who were likely to have a high prevalence of hepatitis C. Although 85% of mothers were tested for HCV, only 72% of those who tested positive went on to have an HCV RNA test to confirm chronic infection; of these, 71% had detectable HCV RNA. The eventual rate of linkage to care for hepatitis C treatment was less than half.

Similarly, of 404 infants born to mothers with HCV, only 45% received a full screening for hepatitis C to confirm that they were not infected.

The study authors say that simplified algorithms for infant testing might improve screening rates. A single HCV RNA test, or an earlier HCV antibody test, might improve diagnosis and retention in care, they suggest. But as in the case of pregnant women, they also draw attention to the lack of licensed therapies for infants and small children.

Psychological relief is the most important benefit of being cured of hepatitis C, say patients

An Australian study of people who were cured of hepatitis C after direct-acting antiviral (DAA) treatment shows that the most frequent outcome reported by patients of achieving a ‘cure’ was being relieved of the psychological burden of living with hepatitis C. The study questioned 20 people cured in 2016 and 2017. Most had been living with hepatitis C for over a decade.

One interviewee reported: “I love not being infectious…That for me has probably been the biggest thing – not having to feel guilty every time I had a blood test done that I might infect somebody, going to the dentist is nowhere near as stressful.”

The authors conclude: "Future engagement strategies targeting people with hepatitis C who are not currently accessing DAA treatment need to use the lived experience of being cured, particularly the significant psychological impact." This should be promoted alongside the benefits to physical health, they say.

Safety and effectiveness of DAAs in older people

Hepatitis C may remain undiagnosed for many years, which means that some people will not learn of their infection until they are over 70. People diagnosed at an advanced age may have been infected for longer and may be more likely to have liver damage. It has been unclear whether conditions more prevalent in older people, such as cardiovascular disease and diabetes, might compromise the effectiveness of hepatitis C treatment.

A study of German patients published last month shows that treatment with direct-acting antivirals (DAAs) is safe and effective in elderly people with hepatitis C virus. Elderly people (aged 70 years and older) were as likely as non-elderly people to be cured (93% vs 91%). Incidence of serious adverse events was somewhat higher in elderly people, though the rate was low.

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