Prioritize Injection Drug Users for Hepatitis C Treatment

Ingrid Hein

July 27, 2017

To eliminate the hepatitis C virus, funding must be prioritized for the treatment of people at high risk of spreading the infection, even if it is at the expense of people at lower risk for transmission, according to one expert at the International AIDS Society 2017 Conference in Paris.

"This means targeting people who inject drugs," said John Dillon, MD, from the University of Dundee in the United Kingdom.

"Average drug users with HCV are likely to infect two to six people before they move away from drug use," he reported. "A focus on treating people who are HCV-positive and injecting is the only way to slow and prevent spread of the virus."

Targeting treatment to patients with advanced liver fibrosis "as a result of the virus has been shown to be a less-effective model for eliminating HCV," Dr Dillon told Medscape Medical News. By selecting patients most likely to spread the disease, the impact will be greater, he added.

In Scotland, more than 85% of the people with a diagnosis of hepatitis C inject drugs, Dr Dillon reported. To date, they have been considered by most treatment services to be "too chaotic to treat" because they are associated with poor adherence to therapy and rapid reinfection, he explained.

"Too Chaotic to Treat"

In their Eradicate-C study, Dr Dillon and his colleagues looked at ways to deliver treatment to this difficult-to-reach population. The team identified and recruited — from treatment centers, community pharmacies that dispense methadone, and needle-exchange centers — 105 patients with hepatitis who were actively injecting drugs over a 42-month period.

Sustained viral response at 12 weeks was measured in 89 of the 94 patients who received treatment, and was achieved by 74 patients (83.1%) — 31 of 38 (81.5%) patients infected with genotype 1 hepatitis C, and 43 of 51 (84.3%) infected with genotypes 2 and 3.

Of the other 15 patients, 14 relapsed and one became reinfected with a different genotype before the end of the 12 weeks.

The rate of reinfection — estimated to be one per 9 patient-years — is compatible with the theory that active drug users can be successfully treated and cured of hepatitis C, said Dr Dillon. This means a "treatment as prevention" strategy would be effective for this group, he explained.

Treating Those in Need

This is preliminary work, he stressed, but reported that "standing outside the doors" of infected drug users seems to be the best way to ensure they get treatment.

"What we did was prove that pathways to reaching these people worked. Nobody believed you could engage with them, so we had to prove that we could," he said. "Now we're upscaling our efforts."

He and his colleagues are currently working to secure funding for a larger trial.

Their treatment model is based on a study in which injection drug users infected with hepatitis C were targeted for early treatment (J Hepatol. 2016;65:17-25). Those researchers found that as the pool of hepatitis C depleted, overall transmission decreased.

They also found that treating injection drug users with moderate or mild hepatitis C is more cost-effective than delaying treatment until patients present with cirrhosis of the liver. And for every mild to moderate case of hepatitis C in an injection drug user that is treated, two new infections are averted.

Treatment as prevention for hepatitis C is gaining support from groups like the World Health Organization (WHO), but it might not be achievable on a mass scale because resources are already depleted for patients with advanced fibrosis. People with milder hepatitis C are not prioritized by healthcare providers or payers, Dr Dillon pointed out.

"The key is having something of a one-stop-shop approach," said Jason Grebely, PhD, from the University of New South Wales in Sydney, Australia.

"The important thing is to bring treatment to the people, not expect people to go to a tertiary-based hospital clinic. You have to provide care where people with the virus are already accessing services," he told Medscape Medical News.

"We also need to continue to pursue evaluation of novel diagnostic testing, strategies to enhance linkage to care, and strategies to improve treatment outcomes," he explained.

Ambitious targets for the elimination of hepatitis C have been set by the WHO, and they are achievable in many countries, but they "will require researchers, healthcare providers, policy makers, affected communities, advocates, the pharmaceutical industry, and diagnostics to work together," said Dr Grebely.

"We also need to work on drug-law reform," he added. "Criminalization of drugs drives people away from services."

Dr Dillon reports receiving research grants and honoraria for lectures from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck Sharp & Dohme, and Roche. Dr Grebely is a consultant and advisor, and has received research grants from AbbVie, Bristol-Myers Squibb, Cepheid, Gilead Sciences, and Merck Sharp & Dohme.

International AIDS Society (IAS) 2017 Conference. Presented July 23, 2017.

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