An international perspective on using opioid substitution treatment to improve hepatitis C prevention and care for people who inject drugs: Structural barriers and public health potential

Abstract

People who inject drugs (PWID) are central to the hepatitis C virus (HCV) epidemic. Opioid substitution treatment (OST) of opioid dependence has the potential to play a significant role in the public health response to HCV by serving as an HCV prevention intervention, by treating non-injection opioid dependent people who might otherwise transition to non-sterile drug injection, and by serving as a platform to engage HCV infected PWID in the HCV care continuum and link them to HCV treatment. This paper examines programmatic, structural and policy considerations for using OST as a platform to improve the HCV prevention and care continuum in 3 countries—the United States, Estonia and Viet Nam. In each country a range of interconnected factors affects the use OST as a component of HCV control. These factors include 1) that OST is not yet provided on the scale needed to adequately address illicit opioid dependence, 2) inconsistent use of OST as a platform for HCV services, 3) high costs of HCV treatment and health insurance policies that affect access to both OST and HCV treatment, and 4) the stigmatization of drug use. We see the following as important for controlling HCV transmission among PWID: 1) maintaining current HIV prevention efforts, 2) expanding efforts to reduce the stigmatization of drug use, 3) expanding use of OST as part of a coordinated public health approach to opioid dependence, HIV prevention, and HCV control efforts, 4) reductions in HCV treatment costs and expanded health system coverage to allow population level HCV treatment as prevention and OST as needed. The global expansion of OST and use of OST as a platform for HCV services should be feasible next steps in the public health response to the HCV epidemic, and is likely to be critical to efforts to eliminate or eradicate HCV.

High prevalence of willingness to use direct‐acting antiviral‐based regimens for hepatitis C virus (HCV) infection among HIV/HCV coinfected people who use drugs

“…daily supervised ingestion of methadone), may result in a subpopulation of PWUD who are more ready and amenable to consider engaging in HCV treatment. Indeed, a growing number of studies suggest that opioid agonist treatment programmes may serve as an important platform to engage PWUD with opioid use disorders in the HCV continuum of care [31]. In contrast, we did not find any impact on willingness to use DAAs of other addiction treatment approaches with less evidence base, including psychosocial-only interventions or withdrawal management alone strategies.…”

“…Importantly, enrolment in MMT was positively associated with willingness to use newer HCV treatments. This finding, alongside previous successful experiences of integration of HIV, HCV and addiction treatment, suggests that multidisciplinary one-stop-shop models of care for PWUD may play a critical role in increasing access to HCV treatment and improving treatment outcomes among this population [29][30][31]. The role of addiction treatment in HCV treatment and prevention outcomes should therefore be further explored [14].…”

Past-year prevalence of prescription opioid misuse among those 11 to 30 years of age in the United States: A systematic review and meta-analysis

“…Public health policy must effectively and systematically address the availability and accessibility of evidence-based treatment of opioid abuse and dependence (e.g., methadone and buprenorphine) to respond to the current opioid epidemic. (Maremmani & Gerra, 2010; Perlman et al, 2015) Programs to prevent fatal overdoses, such as naloxone distribution programs, are critical in addressing preventable drug use-related deaths. (CDC, 2012b) Transition to heroin is an additional and key concern related particularly to misuse of prescription opioids; heroin use has increased in the US by 145% since 2007, and fatal overdoses due to heroin have increased 5-fold during the same time period.…”

Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: An interrupted time series analysis

“…Opioid agonist therapies (OAT), either with methadone or buprenorphine/naloxone, have proved to be effective in reducing illicit opioid use and retaining patients in treatment (Mattick, Breen, Kimber, & Davoli, 2014). OAT has also been shown to reduce illicit drug-related mortality, involvement in criminal activity, as well as to improve HIV and hepatitis C (HCV) prevention and treatment outcomes (Ahamad, et al, 2015; Altice, et al, 2011; Gowing, Farrell, Bornemann, Sullivan, & Ali, 2011; Low, et al, 2016; MacArthur, et al, 2012; Nosyk, et al, 2015; Perlman, et al, 2015). In Canada, methadone maintenance therapy (MMT) has historically been the standard of care of OUD.…”