Is It Justifiable to Withhold Treatment for Hepatitis C from Illicit-Drug Users?

Edlin, Brian R.; Seal, Karen H.; Lorvick, Jennifer; Kral, Alex; Ciccarone, Daniel; Moore, Lisa; Lo, Bernard

doi:10.1056/nejm200107193450311

Cited by 196 publications

(142 citation statements)

References 36 publications

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“…For example, drug users continue to face discrimination from some medical providers who frequently treat them with distrust and disrespect (Chitwood, Sanchez, Comerford, & McCoy, 2001;Crofts, Louie, & Loff, 1997;Day, Ross, & Dolan, 2003;Edlin et al, 2001;Stephenson, 2001;Treloar, Hopwood, & Loveday, 1996;Zickmund, Hillis, Barnett, Ippolito, & LaBrecque, 2004). Also, despite the recent changes to the NIH guidelines regarding HCV treatment, many health care providers have historically been concerned that drug users treated for HCV might have a high risk of re-infection, low treatment compliance, and/or drug relapse (Catz, Kelly, Bogart, Benotsch, & McAuliffe, 2000;Golub et al, 2004;Gordillo, del Amo, Soriano, & Gonzalez-Lahoz, 1999;Hauser et al, 2002;Milby et al, 1996;Osher et al, 2003).…”

Section: Discussionmentioning

confidence: 99%

Exploring drug users’ attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S.

Munoz-Plaza

Strauß

Astone-Twerell

et al. 2008

International Journal of Drug Policy

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Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programmes (MMTPs) reporting that 60-90% of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42-82% of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programmes throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider and/or initiate HCV treatment. Gaining a better understanding of drug users' perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future.

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Section: Discussionmentioning

confidence: 99%

Exploring drug users’ attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S.

Munoz-Plaza

Strauß

Astone-Twerell

et al. 2008

International Journal of Drug Policy

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“…It is also of ethical interest (Edlin et al, 2001). Importantly, the high rates of movement into and out of MMT Chalmers et al, 2009) may mean that the putative advantages incurred by the MMT population in being treated for HCV may largely disappear.…”

mentioning

confidence: 99%

Optimal targeting of Hepatitis C virus treatment among injecting drug users to those not enrolled in methadone maintenance programs

Zeiler

Langlands

Murray

et al. 2010

Drug and Alcohol Dependence

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Background: This work used mathematical modelling to explore effective policy for hepatitis C virus (HCV) treatment in Australia in the context of methadone maintenance treatment (MMT).Method: We consider two models to depict HCV in the population of injecting drug users (IDU) within Australia. The first model considers the IDU population as a whole. The second model includes separate components for those that are or are not enrolled in MMT. The impact of different levels of HCV treatment and its allocation dependent on MMT status were then determined in terms of the steady state levels of each of these models.Results: Although increasing levels of HCV treatment decrease chronic infection prevalence, initially numbers of acutely infected can rise. This is caused by the high rate of reinfection. We find that no matter the extent of HCV treatment, HCV prevalence cannot be eliminated without limiting risk behaviour. Assuming equal adherence to HCV therapy between MMT and non-MMT, over 84% of HCV treatment should be allocated to those not in MMT. Only if adherence to HCV therapy in non MMT patients falls below 44% of that in MMT then treatment should be preferentially directed to those in MMT.Conclusions: Contrary to generally held beliefs regarding HCV treatment the majority of therapy should be allocated to those that are still actively injecting. This is due to rates of reinfection and to the high turnover of individuals in MMT. Higher adherence to HCV therapy in MMT would need to be achieved before this changed.

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“…Consequently, HCV treatment is most advisable for persons at highest risk of fibrosis progression, 3,6 a guideline that becomes even more important in populations such as IDUs in which there is a high incidence of other (competing) medical issues and substantial barriers to traditional medical care. 7,8 Despite the importance of understanding the natural history of liver disease in IDUs and of identifying those in need of treatment, remarkably little published information is available on either topic. One reason is that IDUs do not commonly receive regular care for HCV infection in academic centers, where most natural history studies have been conducted.…”

mentioning

confidence: 99%

Progression of liver fibrosis among injection drug users with chronic hepatitis C

et al. 2006

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Although most hepatitis C virus (HCV) infections are acquired by injection drug use, prospective data on the progression of liver fibrosis are sparse. Baseline liver biopsies were obtained (1996-1998) on a random sample of 210 out of 1667 HCV-positive injection drug users (IDUs). Subjects were followed biannually, with a second biopsy offered to those eligible. Paired biopsies were scored 0 to 6 (modified Ishak score), significant fibrosis was defined as score 3 or greater, and progression of fibrosis was defined as an increase 2 or more units or clinical evidence of end-stage liver disease. Predictive values of blood markers [FibroSURE, aspartate aminotransferase-to-platelet-ratio index (APRI) and alanine aminotransferase (ALT)] were assessed for detection of contemporaneous and future liver fibrosis. Among 119 prospectively followed IDUs, 96% were African American; 97% HCV genotype 1a/b; 27% HIV-infected, and median age was 42 years. Most (90.7%) did not have significant liver fibrosis at first biopsy. Although predictive value for detecting insignificant fibrosis at first biopsy was greater than 95% for FibroSURE, APRI, and ALT, specificities were 88.9%, 72.7%, and 72.7%, respectively. After 4.2 years median follow-up, 21% had progression of fibrosis, which was significantly associated with serum level of HCV RNA and ALT. No serological test had predictive value greater than 40% for contemporaneous or future significant fibrosis. Even initial biopsy result had only a 30.4% value for predicting future significant fibrosis. In conclusion, significant liver fibrosis and progression were detected in some, but not most, IDUs in this cohort. In this setting with low fibrosis prevalence, FibroSURE, ALT, and APRI tests predict insignificant fibrosis; however, further work is needed to find noninvasive markers of significant liver fibrosis. (HEPATOLOGY 2006;43: 788-795.)

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Is It Justifiable to Withhold Treatment for Hepatitis C from Illicit-Drug Users?

Cited by 196 publications

References 36 publications

Exploring drug users’ attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S.

Exploring drug users’ attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S.

Optimal targeting of Hepatitis C virus treatment among injecting drug users to those not enrolled in methadone maintenance programs

Progression of liver fibrosis among injection drug users with chronic hepatitis C

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