Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore

Abstract

Background: Hepatitis C virus (HCV) infection is a major public health issue among people who inject drugs (PWID) with prevalence of 50–80% in the United States. Effective, simple, oral direct acting agents (DAA) of short duration with minimal side effects have been associated with cure rates > 95%. However, HCV treatment uptake among PWID remains low. We characterized the HCV care continuum, HCV treatment knowledge, as well as barriers and facilitators to HCV treatment uptake among PWID enrolled in two opioid treatment programs (OTPs) in Baltimore, Maryland, USA. Methods: Between July and November 2016, 124 HCV infected PWID were recruited from two opioid treatment programs in Baltimore through convenience sampling. Participants completed a 50-item questionnaire to assess HCV treatment knowledge, attitudes, and practices. Progress through the HCV care continuum was assessed based on a series of questions assessing evaluation for HCV treatment, recommendation for HCV treatment by a provider, and HCV treatment initiation. HCV status was assessed based on participant self-report. Results: The median age was 52 years (IQR 44–58), 56% were male, the majority were African American (69%), and 19% reported HIV coinfection. Participants had been tested for HCV at their primary care provider’s (PCP’s) office (34%), drug treatment center (20%), emergency room (11%), or prison (9%), and most (60%) had been diagnosed with HCV over 5 years prior. The majority reported that HCV was a major health concern for them (91%), were aware there were new treatments for HCV (89%), and that the new treatments cure most people (69%). More than half (60%) had seen a health professional who could treat HCV, 40% had HCV therapy recommended by their HCV specialist, and 20% had started or completed treatment. In univariable analysis, PWID were significantly more likely to have been treated if they were HIV co-infected (OR 3.4 (95% CI 1.3–9.2)) or had a partner or friend concerned about their HCV (OR 3.4 (95% CI 1.2–9.7)), and were significantly less likely to have been treated if they had used any illicit drugs in the preceding 6 months (OR 0.4 (95% CI 0.2–0.99). In multivariable analysis, having a friend or partner concerned about their HCV remained significantly associated with HCV treatment (OR 5.0 (95% CI 1.4–17.7)). When questioned about what would facilitate HCV treatment, the majority (85%) reported that a friend telling them that HCV treatment had helped them and having HCV treatment provided at their opioid treatment program would make them more likely to engage in HCV treatment. Conclusion: Despite a high prevalence of HCV among opioid treatment program patients and the availability of effective treatments, uptake remains low. We identified several key barriers and facilitators that can affect HCV treatment uptake.

Epidemiological trends in HCV transmission and prevalence in the Viennese HIV+ population

“…However, addressing barriers to treatment and optimizing drug adherence remain essential in the population of HIV/HCV coinfected individuals . Target‐oriented strategies such as directly‐observed DAA therapy in PWIDs on opioid substitution therapy proved to be effective and may help to overcome barriers and link this subgroup of patients to HCV treatment …”

“…The use of drugs to enhance sexual experience (‘chemsex’) has become a major contributing factor in the current HCV epidemic among MSM as it stimulates high‐risk sexual behaviour including promiscuity, traumatic anal intercourse and extensive sex duration as well as condomless sex, which in turn promotes the transmission of HIV, HCV and other sexually transmitted infections . While in PWIDs, especially in case of ongoing intravenous drug use (IDU) or opioid substitution, rates of HCV diagnosis and treatment uptake still remain low, MSM tend to show high treatment uptake and SVR rates . French data collected between 2012 and 2016 showed a considerable fluctuation in the incidence of HCV reinfections after treatment‐induced SVR in HIV+ MSM that exceeded the incidence of first infections, suggesting that a subgroup of MSM continues to engage in high‐risk practices after SVR …”

“…[9][10][11][12][13] While in PWIDs, especially in case of ongoing intravenous drug use (IDU) or opioid substitution, rates of HCV diagnosis and treatment uptake still remain low, MSM tend to show high treatment uptake and SVR rates. 13,14 French data collected between 2012 and 2016 showed a considerable fluctuation in the incidence of HCV reinfections after treatment-induced SVR in HIV+ MSM that exceeded the incidence of first infections, suggesting that a subgroup of MSM continues to engage in high-risk practices after SVR. 13 The advent of highly effective direct acting antiviral (DAA) has revolutionized HCV treatment.…”

“…drug adherence remain essential in the population of HIV/HCV coinfected individuals 23,26. Target-oriented strategies such as directly-observed DAA therapy in PWIDs on opioid substitution therapy proved to be effective and may help to overcome barriers and link this subgroup of patients to HCV treatment 14,[42][43][44][45]. 5%) and the high rate of persisting HCV viraemia (89/208; 42.8%) at last FU were partially attributed to loss to FU.…”

Network‐based recruitment of people who inject drugs for hepatitis C testing and linkage to care

“…To achieve HCV elimination goals, HCV treatment uptake among PWID must increase 20 . Patient, provider and system level barriers have been extensively detailed in previous research and have been linked to low treatment uptake among PWID 21‐25 …”