UK community test-and-treat service achieves high hepatitis C cure rate in people who use drugs

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.

The 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.

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.