Untreated alcohol use disorder in people who inject drugs (PWID) in France: a major barrier to HCV treatment uptake (the ANRS‐FANTASIO study)

Abstract

Background and Aims Although people who inject drugs (PWID) are the core at‐risk population in the hepatitis C virus (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well‐tolerated HCV treatments (direct‐acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon‐based treatments: Peg‐IFN). Design Using discrete‐time Cox proportional hazards models based on exhaustive care delivery data, we tested for associations between AUD (defined by AUD‐related long‐term illness status, diagnosis coding during hospitalization and/or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of opioid agonist therapy (OAT) received. Separate analyses were performed for 2012–13 (Peg‐IFN era) and 2014–16 (DAA era). Setting France. Participants All French people chronically HCV‐infected who received OAT at least once during 2012–16 and were covered by the national health insurance (n = 24 831). Measurements Incidence rate of HCV treatment uptake, hazard ratios associated with AUD and other covariates. Findings Incidence rate (IR) of HCV treatment uptake per 100 person‐years was 6.56, confidence interval (CI) = 6.30–6.84; and IR = 5.70, 95% CI = 5.51–5.89 for Peg‐IFN‐based treatment (2012–13) and DAA (2014–16), respectively. After multiple adjustment, people with AUD not receiving related medication had 30 and 14% lower Peg‐IFN‐based treatment and DAA uptake, respectively, than those without AUD [hazard ratio (HR) = 0.70, 95% CI = 0.62–0.80 and HR = 0.86, 95% CI = 0.78–0.94]. No difference was observed between those treated for AUD and those without AUD. Conclusions Despite the benefits of direct‐acting antiviral treatment, untreated alcohol use disorder appears to remain a major barrier to hepatitis C virus treatment access for people who inject drugs in France.

Low hepatitis C virus-viremia prevalence yet continued barriers to direct-acting antiviral treatment in people living with HIV in the Netherlands

“…Additionally, those with advanced fibrosis or cirrhosis more often received DAAs, likely owing to the specific restrictions put in place in these settings [8–11]. Regarding alcohol use, similar to what we observed, severe alcohol use was associated with a lower DAA-uptake in a study in HCV-infected individuals receiving opioid agonist therapy [21], which was not confirmed in a smaller study among HIV-positive PWID [22]. Of note, both studies analyzed severe alcohol use at a cut-off that was higher than the cut-off of >20 units/week in our cohort.…”

Hepatitis C virus: A critical approach to who really needs treatment

“…Those with shorter periods of drug dependence had the highest compliance with an inadequate 47% compared with the even worse 38% of longer-time users[ 39 ]. In France, drug uptake was low in HCV patients with PWID and alcohol use disorders (AUD) despite an improvement after DAA introduction as compared to interferon (IFN)-based treatments[ 40 ].…”

Life after hepatitis C cure in HIV‐infected people who inject drugs and men who have sex with men treated with direct‐acting antivirals in France: Health perceptions and experiences from qualitative and quantitative findings (ANRS CO13 HEPAVIH)

“…The introduction of DAA has thus probably significantly transformed the health experiences, outcomes and trajectories of HIV‐HCV–co‐infected individuals. However, even if epidemiological data exist to describe global access to DAA and remaining barriers, 9‐11 experiences and trajectories of HIV‐HCV–co‐infected individuals after DAA treatment remain poorly documented in France. This knowledge gap is particularly present for HIV‐HCV–co‐infected people who inject drugs (PWID) (including both people with current injecting drug practices and people with a history of drug injection) and men who have sex with men (MSM), two populations with historically high rates of HIV‐HCV co‐infection and who also experience a variety of social and structural barriers to health care and treatment services 12 .…”