Harm Reduction Programs Lower Rate of Hep C Reinfection

Ingrid Hein

September 19, 2019

MONTREAL — The Arud Centre for Addiction Medicine in Zurich opens early in the morning so that patients can get a hit of heroin before going to work.

"We know that when [these patients] inject in the morning, a lot of time they are more stabilized and stop using other things," said Claudia Bernardini, MD, an attending physician at Arud.

The clinic also has infectious disease specialists on site for the testing and treatment of hepatitis C and other diseases, and provides syringes, mental health therapy, help finding accommodation, and other services. And people who no longer want to inject can pick up methadone pills.

"We try to make it easy for patients," Bernardini explained. "We have nurses, people who work in restaurants; all kinds of people come in."

Contact with the clinic can be made over the phone, by email, or in person. Patients can remain anonymous if they choose.

This integrated-care approach could be responsible for the low reinfection rates of hepatitis C seen at the clinic, Bernardini suggested here at the International Conference on Hepatitis Care in Substance Users 2019.

She and her colleagues assessed clinic patients with a diagnosis of opioid- or stimulant-use disorder who were receiving direct-acting antiretroviral therapy for the treatment of hepatitis C.

Of the 57 study participants, 24 (42%) reported lifetime injection-drug use, and 97% of the study cohort was receiving opioid agonist therapy.

At 24-week follow-up, only one reinfection was detected, which translates into a reinfection rate of one per 100 person-years of follow-up.

High Rate of Reinfection Among Injection-Drug Users

Rates of hepatitis C reinfection are generally higher in people who are injection-drug users, as was demonstrated in other presentations during the session on hepatitis C reinfection.

Results from a meta-analysis of 35 studies of reinfection in drug users, comprising 6303 person-years of follow-up, were reported by Behzad Hajarizadeh, PhD, from the Kirby Institute for Infection and Immunity in Sydney, Australia.

The reinfection rate was 5.9 per 100 person-years of follow-up for people who reported recent injection-drug use, 5.7 per 100 person-years of follow-up for people who reported recent drug use, and 3.8 per 100 person-years of follow-up for those receiving opiate substitution treatment.

The risk for reinfection was higher in people who had used drugs recently, but the researchers were not able to quantify that increase because of a lack of information in the studies they evaluated, Hajarizadeh reported.

He hypothesized that there would be a higher risk for reinfection early on after treatment. "We saw lower rates in studies with longer follow-up," he noted. However, this could have been the result of "the cohort effect."

"People who have a higher risk for reinfection may be excluded from the data earlier, as they are lost to follow-up, drop out, etc," he pointed out.

Reinfection is part of the reality for people who inject drugs after they've been treated with direct-acting antiretrovirals for hepatitis C, but centers with extensive harm-reduction programs have lower rates of reinfection, Hajarizadeh said.

A Multidisciplinary Program

Like the Arud clinic, a clinic in the Lower East Side neighborhood of Vancouver, Canada reports low reinfection rates for people who inject drugs.

Brian Conway, MD, from the Vancouver Infectious Diseases Centre, said that the "four-legged chair" services at his center — medical, social, psychologic, and addiction — help reduce reinfection rates.

He and his colleagues followed 234 patients who had achieved a sustained viral response after direct-acting antiviral therapy for a median of 714 days. In the study cohort, 195 people were current injection-drug users, 78% of the cohort was treatment-naïve, and 17% had cirrhosis.

Because of the multidisciplinary aspects of the program, reinfection rate in this cohort was 1.7%, Conway reported.

"We engage individuals, helping to address housing insecurity, food insecurity, and financial insecurity. We offer opioid agonist therapy, syringe programs, and education about harm reduction and medically dangerous overdoses," he explained. The program also helps patients get into recovery programs, "if they're interested."

When healthcare providers engage people in a holistic manner, they can gather information by asking patients where they eat, what pharmacy they use, and whether they have an email address. "This is all part of the program so there's less loss to follow-up and they trust us more," Conway explained.

Not Reaching Highest-Risk Populations

However, low reinfection rates might indicate that people at highest risk are not being reached, said Gregory Dore, PhD, from the viral hepatitis clinical research program at the Kirby Institute.

"If you see no reinfection, then almost certainly the population you're treating is at very low risk for hepatitis C acquisition reinfection," he said.

Australia is leading the global response to hepatitis C infection, and 40,000 people have been treated since 2016. "We've treated about half the current injecting population," he reported, and "have broad implementation of harm-reduction strategies."

Access to needle-exchange programs is good and there is "pretty good access to methadone," Dore noted.

But if you go to Australian cities where harm-reduction coverage is poor, "you start seeing reinfection at very high rates," he said.

When researchers report low reinfection rates, they are likely treating a much more stable population. "Many of them may be injecting but, within the injecting population, they are more stable; the risk of transmitting is relatively low," he said.

Dore reported final Australian data from the CO-STAR phase 3 trial (NCT02105688).

After 12 weeks of treatment with the combination of elbasvir and grazoprevir, reinfection rates in people receiving opioid agonist therapy were low, at 1.7 reinfections per 100 person-years of follow-up.

Everyone should have access to treatment, "and treating these people is good," Dore said. However, "by treating this population, you're not going to change the shape of the epidemic very much; they are not the ones transmitting the virus."

Without reaching the high-risk population of injection-drug users, "we're never going to reach WHO targets — one of which is an 80% reduction in new infections — unless we treat the very-high-risk populations," Dore said.

Bernardini reports receiving travel grants from AbbVie and Gilead . Hajarizadeh has disclosed no relevant financial relationships. Conway reports receiving grants, honoraria, travel funding, and advisory board positions from AbbVie, Merck & Co, Gilead Sciences, and ViiV. Dore reports receiving grants, personal fees, and nonfinancial support from AbbVie, Merck, Bristol-Myers Squibb, and Roche; grants and personal fees from Janssen; personal fees and nonfinancial support from Gilead Sciences; and personal fees from GlaxoSmithKline and Abbott Diagnostics.

International Conference on Hepatitis Care in Substance Users (INHSU) 2019. Presented September 13, 2019.

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