CATIE News

21 June 2016 

Strategies for improving the hepatitis C care continuum for people who inject drugs

Hepatitis C treatment has changed dramatically in the past few years, with the development of medications that have cure rates of 90% and greater, few side effects and short durations, often just a few months. While these new medications are an exciting improvement, only a small percentage of people who inject drugs are able to access care and treatment for hepatitis C. Given that people who inject drugs are greatly affected by hepatitis C in Canada, improved access to the continuum of hepatitis C care is a current need in this country.

Researchers in the U.S. conducted a systematic review of interventions to improve access to hepatitis C care for people who inject drugs. The researchers grouped and reviewed the interventions based on the following stages across the hepatitis C care continuum:

  • diagnosis or case finding (6 studies)
  • linkage to care (20 studies)
  • pre-therapeutic evaluation or treatment initiation (7 studies)
  • treatment adherence (17 studies)

Interventions targeting diagnosis or case finding

The researchers found that focusing hepatitis C testing on people who are part of groups most affected by hepatitis C in settings they are likely to frequent (people who inject drugs in harm reduction programs, for example) was effective when it came to increasing rates of testing and diagnosing people with hepatitis C. Populations in these settings included people attending a substance use treatment clinic; people attending a mobile medical clinic; people attending a primary care clinic that had a methadone prescriber; prisoners; and people with serious mental health and/or substance use issues in a community mental health program.

These studies used a variety of interventions, such as the following:

  • free counselling and testing
  • point-of-care testing
  • a combination intervention of blood tests, vaccines, case management and counselling – also called streamlined screen-test-immunize-reduce risk-refer protocols (SSTIRR)

These programs were effective at finding new cases of people with hepatitis C compared to the usual care but they required structural support, such as financial resources.

Interventions targeting linkage to hepatitis C care

Interventions designed to link people to hepatitis C care took place in primary care settings, prisons and substance use treatment centres that provide opiate substitution therapy (OST). In these settings, some interventions used multidisciplinary team models or peer-based models.

Primary care settings:

Primary care clinics that have established relationships with marginalized populations, such as people who inject drugs or who are homeless, are well positioned to link people to hepatitis C care.

Studies showed that people who use drugs and/or have serious mental health issues can be linked to care and treatment within these settings.

Some examples of effective linkage to hepatitis C care in primary care settings included:

  • multidisciplinary medical group visits to a homeless clinic to integrate care
  • public health nurses and doctors working in partnership to link patients to care in rural Canada

The researchers suggested in the systematic review that with newer hepatitis C treatments that are easier to take and have fewer side effects it is possible for hepatitis C treatment to shift to the primary care setting to a greater degree.

Substance use treatment centres:

As there is a high prevalence of hepatitis C among participants in substance use treatment programs, these settings are ideal places to link people to hepatitis C care.  

In these centres people were connected to hepatitis C treatment at different times in the substance use treatment cycle. One study demonstrated that hepatitis C treatment could be started while people were in a detoxification program instead of requiring participants to be off drugs for six months to one year before starting treatment.  

Other programs connected people who were already participants in opiate substitution programs to hepatitis C treatment. These projects showed similar uptake of hepatitis C treatment compared with populations of people who did not inject drugs.

All of the substance use programs with linkage to care programs used a multidisciplinary approach combining substance use and medical treatment and provided comprehensive social support.

Prisons:

Prisons could potentially be a key setting for hepatitis C care because of the high prevalence of hepatitis C and a structured environment that could support care delivery; however, as found in the systematic review, this setting is not well utilized.

Few interventions were found in this review but one prison intervention had an outreach nurse who connected people to hepatitis C treatment.

Peer models of linkage to care:

Peer models where people with hepatitis C provide each other with support and education are an efficient way to link people to care, especially among people who inject drugs.

One model was a service-provider-led group where participants started treatment at the same time and stayed in the group together for part or all of treatment. Participants received support from each other to get through treatment. Participants were able to attend medical appointments on-site while the group was taking place.

While this and other peer-based interventions are promising, further evaluations are needed.

Interventions targeting pre-therapeutic evaluation or treatment initiation

For people who inject drugs there are a number of barriers to accessing hepatitis C treatment, including providers deferring or not referring treatment because of current drug use and concerns about adherence, the mental health impact of treatment and re-infection. Despite these barriers, several projects have shown that people who use drugs can get through hepatitis C treatment and be cured with appropriate supports.

Two peer-based programs using the Organization to Achieve Solutions in Substance Abuse (OASIS) model, which used a biopsychosocial model and buprenorphine therapy to improve access to hepatitis C treatment, resulted in 15% (53 out of 352) to 28% (57 out of 204) of participants accessing treatment.

One model involving doctors, pharmacists and care coordination with people whose treatment was postponed due to a mental health or substance use issue. Participants received care from a hepatologist and a behavioural intervention by a psychologist. Participants in this intervention were 2.4 times more likely to start treatment within nine months than people receiving the standard of care.

As noted in the systematic review, as new medications that are easier to take become more widely available, extensive pre-therapeutic evaluations may not be as necessary for certain groups.

Interventions targeting treatment adherence  

In the studies reviewed, treatment adherence was commonly measured by self-report, pill counts, pharmacy refills (or dispensing) or with a special pill container that records when it is opened (also known as a medication event monitoring system).

Some of the studies used a modified form of directly observed therapy (DOT) with the older hepatitis C medications, where people received the weekly peg-interferon injection or one daily dose of ribavirin. This type of program was effectively delivered within a number of settings, including opiate substitution programs, prisons and multidisciplinary health clinics.

Conclusions

The majority of the research in this systematic review was conducted on treatment regimens that included interferon, which required extensive workups prior to treatment, intensive support during treatment to manage side effects, and a lengthy treatment time. With new hepatitis C  treatments, treatment is much easier to take but many of the key points from this review are still relevant.

For example, providing testing, care and support for people with hepatitis C in settings that they are already accessing and feel comfortable in will continue to be important for reaching populations that don’t access mainstream healthcare services, such as people who inject drugs.  

Providing hepatitis C care using multidisciplinary teams will likely continue to be necessary for people who struggle with multiple health issues in addition to hepatitis C and who need help obtaining other supports, such as housing and income.

While concern has been expressed about people who inject drugs being at risk of hepatitis C re-infection, a recent systematic review found that re-infection rates were low among this group (less than one to five people re-infected per year). 

Given that this review did not find any research about care post-hepatitis C treatment, this is a key area for future care continuum interventions. This is important because people with cirrhosis need to be monitored for liver cancer even after they have been cured with hepatitis C treatment.

—Scott Anderson

Resources

CATIE's hepatitis C information

Pre-fix: A guide for people with Hep C or HIV who inject drugs

HepCInfo on Newsprint - Issue 3

REFERENCES:

  1. Grebly, J, Robaeys G, Bruggmann P Recommendations for the management of hepatitis C virus infection among people who inject drugs. International Journal of Drug Policy. 2015;26: 1028-1038.
  2. Meyer JP et al. Evidence-based interventions to enhance assessment, treatment and adherence in the chronic Hepatitis C care continuum. International Journal of Drug Policy. 2015;26: 922-935.