Offering hepatitis C testing and treatment through a community
drugs and alcohol service led to high uptake of testing and treatment among
current and former injecting drug users, as well as a high cure rate, Professor
Sumita Verma of Brighton and Sussex Medical School reported at last week’s
AASLD Liver Meeting in Washington DC.
Treatment response was not affected by homelessness, current
drug use or alcohol use, demonstrating that hepatitis C can be taken successfully
by people with unstable living situations who are substance users, challenging
preconceptions that this group is hard to treat.
ITTREAT project (Integrated community-based Test - stage - TREAT) is a
hepatitis C testing and treatment scheme based in the Substance Misuse Service
in Brighton, in the south-east of England. The project was established in 2013 and
provides dried blood spot testing for HCV antibody, HCV RNA testing, transient
elastography (Fibroscan) to stage liver disease, and direct-acting
antiviral treatment. The service also provides opioid substitution treatment for
people who inject drugs; current injecting or alcohol use are not barriers to
starting direct-acting antiviral treatment.
A non-invasive test, used instead of a biopsy, to measure the stiffness
or elasticity of the liver using an ultrasound probe.
All services are provided in the community by a hepatitis specialist nurse based in the service at a site
familiar to drug users. People requiring direct-acting antiviral treatment
can arrange for home delivery of medication or collection from the service, for
example if they are attending for methadone treatment.
Professor Verma reported on outcomes of treatment in 765 service users recruited to the study, 94% of whom consented to HCV antibody testing between 2013 and 2021.
Seventy-eight per cent were men and the mean age of those tested
was 40 years. Just over a third were current injectors and 55% were receiving
opioid agonist treatment. The majority (55%) were homeless at the time of
testing and 39% had a current alcohol use disorder.
Sixty-five per cent had a positive antibody test result and just over half of those recruited (53%) were positive for HCV
RNA and 18% had stage F4 fibrosis. Overall, 75% with a positive HCV RNA result received
treatment, 90% with direct-acting antivirals. Treatment uptake was strongly
associated with alcohol use (OR 2.57), a psychiatric diagnosis (OR 2.75) and F4
fibrosis (OR 3.24). People who were currently injecting drugs were
significantly less likely to start treatment than those who were not current
injecting drug users (OR 0.52).
Of those who received direct-acting antiviral treatment
(280), 86% were cured of hepatitis C. Sustained virologic response was not
affected by cirrhosis, genotype or any demographic factor, including
homelessness, current injecting drug use, current alcohol use or psychiatric
diagnosis. Although the prevalence of current injecting drug use and
homelessness increased in the period 2017-2021 compared with the period
2013-2017, there was no significant difference in cure rates. The rate of
reinfection fell from 11.07 per 10,000 person-years in 2013-2017 to 1.34 per
10,000 in 2017-2021.
The only factors that significantly reduced the likelihood of cure were adherence of less than 80% and not taking opioid substitution treatment.