Treatment uptake and outcomes among current and former injection drug users receiving directly observed therapy within a multidisciplinary group model for the treatment of hepatitis C virus infection

Abstract

Injection drug use accounts for the majority of incident and prevalent cases of hepatitis C virus (HCV) infection. However, very few injection drug users (IDUs) have received treatment for this condition given issues of medical or psychiatric co-morbidity, ongoing substance abuse and a widely held belief that such individuals will not be able to adhere to the requirements of therapy, including regular medical follow-up. With this in mind, we sought to evaluate HCV treatment uptake and outcomes among current and former IDUs attending a weekly peer support group and receiving directly observed HCV therapy. Utilizing the existing infrastructure for the management of addictive disease, we have developed a model of "one-stop shopping" whereby the treatment of addiction, HCV and other medical conditions are fully integrated, with the collaboration of nurses, counsellors, addiction specialists, infectious disease specialists, primary care physicians and researchers. Subjects interested in receiving treatment for HCV infection were referred to a weekly peer-support group and evaluated for treatment. Patients received therapy with pegylated interferon-alpha2a or -alpha2b, both in combination with ribavirin. All injections were directly observed. Overall, we observed a high uptake of HCV treatment among attendees, with 51 percent either receiving or about to receive therapy. To date, 18 patients have initiated treatment for HCV infection and 12 have completed therapy. Overall, 8/12 (67 percent) subjects achieved an end of treatment response (genotype 1, 67 percent; genotypes 2/3, 67 percent), despite ongoing drug use in 75 percent of patients during treatment. These data demonstrate that with the appropriate programs in place, a high uptake of HCV treatment can be achieved among IDUs referred to a peer-support group. Moreover, the treatment of HCV in current and former IDUs within a multidisciplinary DOT program can be successfully undertaken, resulting in ETRs similar to those reported in randomized controlled trials.

Can antiviral treatment for hepatitis C be safely and effectively delivered in primary care?

“…The finding of the feasibility of communitybased treatment provision to those who inject drugs is confirmed by another Canadian study conducted by Grebely et al 17 Community-based treatment provision to such individuals was through a multidisciplinary team model comprising both primary and secondary care clinicians. Of the participants, 65% achieved an end of treatment response (ETR) despite the fact that three-quarters of all recruited patients reported ongoing drug use.…”

“…Several commentators have recommended that antiviral therapy can, and should, be delivered in the multidisciplinary primary care setting when focused on areas of high prevalence of HCV. 4,[8][9][10]15,17,[27][28] The findings of the current review have suggested that such primary care-based treatment is feasible with support from specialists. Such a model has treatment outcomes that are equivalent with secondary care services.…”

Mathematical modelling of hepatitis C treatment for injecting drug users

“…Preliminary studies on treatment uptake indicate that willingness to enter treatment is high among active injectors (Grebely et al , 2007). Further, a recent review of treatment of active IDUs notes that treatment compliance and success rates are equal between active IDU and ex-or non-IDU (Hellard et al , 2009).…”

Comment on the updated AASLD practice guidelines for the diagnosis, management, and treatment of hepatitis C: Treating active drug users #

“…3 The literature offers several examples of successful models for delivering HCV care and treatment to active drug users. [4][5][6][7][8][9][10][11] We hope that this contradiction is resolved so that the Practice Guidelines are internally consistent in suggesting that clinicians broadly consider HCV treatment for active drug users in the context of supportive, multidisciplinary care.…”