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 recommendation 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.
Grebely J et al for International Network for Hepatitis in Substance Users. Recommendations for the management of hepatitis C infection among people who inject drugs. Int J Drug Policy 26: 1028-1038, 2015.