Hepatitis C Diagnosis and Treatment, Impact on Engagement and Behaviour of People Who Inject Drugs, a Service Evaluation, the Hooked C Project

Madeleine Caven; Emma M. Robinson; Ann J. Eriksen; Emma H. Fletcher; John F. Dillon

Disclosures

J Viral Hepat. 2020;27(6):576-584. 

In This Article

Abstract and Introduction

Abstract

There is emerging evidence that Hepatitis C (HCV) treatment engagement is associated with change in drug behaviours and reduced drug-related death rates among people who inject drugs (PWID). The project aims to investigate whether HCV diagnosis and treatment engagement reduces all-cause mortality and drug-related death, and whether any effect is dependent on treatment regimen and intensity of engagement with staff. Case-control studies comparing: PWID with active HCV infection (PCR positive) to PWID HCV infected but spontaneously resolved (PCR negative); PCR-positive patients who engaged with treatment services to nonengagers; and patients who received interferon vs direct-acting antiviral (DAA) based treatment. No differences in risk of all-cause mortality or drug-related death between PCR-negative controls and PCR-positive cases were detected. The odds of all-cause mortality was 12.2 times higher in nonengaging persons compared to treatment engaging cases (aOR 12.15, 95% CI 7.03–20.99, P < .001). The odds of a drug-related death were 5.5 times higher in nonengaging persons compared with treatment engaging cases (aOR 5.52, 95% CI 2.67- 11.44, P < .001). No differences in risk of all-cause mortality or drug-related death between interferon-treated cases and DAA-treated controls were detected. HCV treatment engagement is significantly protective against all-cause mortality and drug-related death. This engagement effect is independent of treatment regimen, with the introduction of DAA therapies not increasing risk of drug-related death, suggesting intensity of HCV therapy provider interaction is not an important factor.

Introduction

Hepatitis C (HCV) is a blood-borne virus and affects up to 1% of the Scottish Population.[1] Around 90% of those infected with HCV acquire the virus through injecting drug use behaviour.[2] HCV related liver disease is a primary contributor to morbidity and mortality among people who inject drugs (PWID).[3] HCV is preventable, treatable and curable, with research supporting the treatment of active injecting drug users for Hepatitis C.[4] The efficacy of pan-genotypic direct-acting antivirals (DAA) provides an excellent opportunity to scale up HCV diagnosis and treatment, ultimately achieving the WHO target of HCV elimination by 2030.[5,6]

There is evidence that HCV care engagement is associated with change in behaviours among PWID. Studies have demonstrated the positive impact of HCV status notification on reduction in injecting behaviour among PWID.[7,8] Furthermore, a systematic review highlighted the positive impact of HCV treatment on patients' injecting and sharing behaviour.[9]

The causes of death among PWID are strongly associated with active drug use.[10] Scotland has observed a twofold increase in drug-related deaths between 2008 and 2018, with Tayside experiencing the highest number of drug deaths ever recorded in the region in 2018.[11,12] It is vital that informed action is urgently undertaken to reverse this trend.

The introduction of Multidisciplinary Managed Care Networks (MCN) in HCV treatment has increased access to services and reduced all-cause mortality.[13] The associated improvement in access into care and HCV treatment may have led to a greater degree of engagement with health services and may have had a stabilizing effect on drug using behaviour. However, there is concern around the potential impact of reduction in intensity of staff contact when transitioning from the interferon era to the DAA era of treatment. Interferon based treatment required a greater intensity of staff to patient engagement due to adverse side effects and long treatment duration. Contrastingly, DAA based treatment has minimal side effects and higher cure rates (in excess of 95%).[14] Thus, treatment pathways are streamlined and arguably provide less opportunity for patients to develop a therapeutic relationship with healthcare professionals involved in their care, and therefore reduced opportunities to facilitate change in patients' drug use behaviour, and lower risk of mortality.

The aims were to investigate whether HCV diagnosis and engagement in treatment services reduced all-cause mortality and drug-related death, and whether any effect was dependent on treatment regimen or intensity of engagement with staff. A series of retrospective case-control studies were carried out. Initially, comparing PWID with active HCV infection (PCR positive) vs PWID who were HCV infected but cured spontaneously (PCR negative), to elucidate whether knowledge of HCV infection status impacted risk of mortality. Secondly, comparing PCR-positive patients who engaged vs did not engage with treatment services to assess if outcomes were dependent on engagement. Finally, comparing interferon treated patients vs DAA-treated patients, exploring the effect of intensity of HCV therapy provider interaction on outcomes.

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