Excellent hepatitis C virus cure rates despite increasing complexity of people who use drugs: Integrated‐Test‐stage Treat study final outcomes

Abstract

Achieving hepatitic C virus (HCV) elimination requires linking people who use drugs (PWUD) into care. We report final direct‐acting antivirals (DAAs)‐based outcomes from the Integrated‐Test‐stage ‐Treat (ITTREAT) study. Project ITTREAT (2013–2021), based at an addiction centre, was a ‘one‐stop’ service with innovative linkage to care strategies. Primary outcome was sustained virological response (SVR12) (intention to treat ITT) including whether individuals were recruited in first (period 1) versus last four (period 2 included the COVID‐19 pandemic) years of the study. Number recruited were n = 765, mean age 40.9 ± 10.1 years, 78% males, history of current/past injecting drug use (IDU) and alcohol use being 77% and 90%, respectively. Prevalence of a positive HCV PCR was 84% with 19% having cirrhosis. Comparing those recruited in period 2 versus period 1, there was increasing prevalence of IDU, 90% versus 72% (p < .001); homelessness, 67% versus 50% (p < .001); psychiatric diagnosis, 84% versus 50% (p < .001); overdose history 71% versus 31% (p < .001), receiving opioid agonist treatment (OAT) 75% versus 52% (p < .001) and comorbidity 44% versus 25% (p < .001). Of those treated with DAAs (n = 272), ITT SVR rates were 86% (95% CI: 81%–90%), being similar in period 2 versus period 1. Predictors of non‐SVR were receiving OAT (OR 0.33, 95% CI: 0.12–0.87, p = .025) and ≥80% adherence (OR 0.01, 95% CI: 0.003–0.041, p < .001). Reinfection rates period 2 versus period 1 (per 100 person‐years) were 1.84 versus 1.70, respectively. In the treated cohort, mortality was 15%, being mostly drug‐related. Despite increasing complexity of PWUD, high SVR12 rates are achievable with use of OAT and good adherence.

A framework for approaching hepatitis C reinfection in people who use drugs

“…In another UK study of 270 PWID who received HCV treatment at an addiction center observed 41 deaths (15%) during the 8-year study period; drug overdose was the most common cause of death among those whose cause of death could be ascertained. [16] In a third Canadian study of people living with HIV in clinical care, mortality was three times higher in individuals who experienced HCV reinfection after initial SVR. [14] These data underscore the importance of addressing non-liver outcomes and the syndemic of opioid use and viral infections in patients at high risk of HCV reinfection.…”

“…[10] Several additional studies have since been published, with reinfection rates ranging from 1.8/100 PY (95% CI: 0.6-5.6) in a UK cohort treated at an addiction center to 28.7/100 PY (95% CI: 16.3-50.6) among persons in an Australian prison who reported recent IDU and sharing of needles/syringes (Table 1). [11][12][13][14][15][16][17][18][19][20] In addition to IDU, factors associated with higher rates of reinfection include younger age, experiencing unstable housing or homelessness, receipt of HCV treatment while in prison, and recent needle or syringe sharing. [11,13,15,19] Notably, much of this research has been conducted outside of the United States.…”

“…The mortality rate was also high at 5.6/100 PY (95% CI: 2.8–11.1) and was predominantly due to drug overdose or other complications of drug use. In another UK study of 270 PWID who received HCV treatment at an addiction center observed 41 deaths (15%) during the 8-year study period; drug overdose was the most common cause of death among those whose cause of death could be ascertained 16 . In a third Canadian study of people living with HIV in clinical care, mortality was three times higher in individuals who experienced HCV reinfection after initial SVR 14 .…”