Changes in Alcohol Use During Hepatitis C Treatment in Persons who Inject Drugs

Madhuri Martin; Prerana J. Roth; Jiajing Niu; Irene Pericot-Valverde; Moonseong Heo; Akhila Padi; Brianna L. Norton; Matthew J. Akiyama; Alain H. Litwin


J Viral Hepat. 2022;29(11):1004-1014. 

In This Article

Abstract and Introduction


People who inject drugs (PWID) are a vulnerable population at high risk for acquiring hepatitis C virus (HCV) and frequently suffer from comorbid alcohol use. This study examines the characteristics and correlates of alcohol use among study participants, the association between alcohol consumption and sustained virologic response (SVR) in patients receiving HCV treatment, changes in drinking behaviours during HCV treatment and associations of drinking over time with specific models of HCV treatment. Participants were 150 PWID with HCV who were receiving opioid agonist therapy (OAT) and enrolled in a randomized clinical trial exploring the effectiveness of three models of care for HCV treatment. The addiction severity index was the primary measure of alcohol consumption. Days of alcohol intake were evaluated longitudinally and across three treatment groups. At baseline, 31% (47/150) reported having at least one drink in the last 30 days including 24% (36/150) who reported drinking to intoxication in the last 30 days. There was no difference in SVR rates between groups. There was a significant decrease in overall days of drinking from baseline (7.78 ± 7.86) to follow-up at Week 24 (5.78 ± 8.83) (p = 0.041), but there were no significant changes among those who drank to intoxication; modified directly observed therapy (mDOT) was the only group with a significant decline in days of alcohol consumption (p = 0.041). In this cohort of PWID on OAT, baseline alcohol consumption did not affect SVR rates. HCV treatment was overall associated with decreased alcohol consumption. In particular, mDOT was associated with decreased alcohol consumption. Given the additive effect of alcohol and HCV on the development of cirrhosis, studies should be done to investigate the complimentary effects of the mDOT model of care on alcohol cessation.


The burden of hepatitis C virus infection (HCV) remains disproportionately high among people who inject drugs (PWID). According to a 2017 review, an overall estimated prevalence of HCV among PWID in the United States was 53%.[1] Alcohol use concurrent with HCV infection accelerates fibrosis progression and can worsen all-cause mortality.[2] There is a wide range of rates of alcohol consumption in PWID with HCV diagnosis. In the German Hepatitis C Registry, 17.9% of people with HCV on opioid agonist therapy (OAT) reported alcohol use.[3] In a multi-centre international study of people with HCV and either recent injection drug use or on OAT, 69% reported alcohol use.[4] HCV and alcohol use among PWID remain common; optimizing treatment for both issues is high priority.

Historically, individuals infected with HCV with concurrent drug and alcohol use were excluded from HCV treatment due to concerns for poor adherence, high cost of treatment and risk of re-infection.[5] The impact of alcohol use on adherence is an area of ongoing investigation. The most recent guidelines (HCV)[6] state that baseline drug and alcohol use do not affect adherence, and patients should not be excluded from HCV treatment.[7] Several studies in non-PWID populations demonstrate that alcohol use is not associated with decreased SVR.[8,9] However, there are limited studies examining whether alcohol use decreases SVR in PWID.

Studies examining alcohol use during HCV treatment for PWID (with and without alcohol-specific interventions) are limited.[10–13] To date, results are variable regarding both the type of interventions used and their impact on alcohol consumption. Data for interventions in the current era of direct-acting antivirals (DAA) therapy are even more limited. In a small study offering HCV treatment to patients receiving OAT published by Watson et al., a brief intervention regarding alcohol use resulted in a 3.1 grams per day decline in alcohol consumption.[13] However, a multi-centre international study describing patterns of injection drug use and alcohol use showed no change in alcohol use during HCV treatment.[14]

The aims of this study were to (1) identify the baseline characteristics and correlates of alcohol consumption among study participants; (2) assess whether alcohol consumption is associated with decreased sustained virologic response (SVR) rates in PWID; (3) assess whether alcohol consumption changed over the course of HCV treatment among a cohort of HCV-infected PWID on OAT; and (4) explore alcohol use among three models of HCV care delivered on-site at the OAT programme.