The hepatitis C virus (HCV) affects 2–15% of people living with HIV. Of those affected, up to 90% are people who inject drugs (PWID). This is not shocking given that injection drug use (IDU) is the most common risk factor for acquiring HCV infection. Substance use, past or present, can play a big role in a person’s health and access to medical care. Likewise, substance use may impact one’s access to HCV treatment.
For people living with HIV/HCV co-infection, this is especially concerning. HIV co-infection speeds up fibrosis (liver scarring) progression in those living with HCV, compared to people who have HCV alone. Thus, an unnecessary delay in therapy may lead to irreversible, yet avoidable, liver damage.
Barriers to HCV treatment in PWID
Studies published over the last decade show HCV treatment to be effective in PWID, but stigma surrounding IDU remains. Some healthcare providers may hesitate to prescribe treatment for PWID out of concern for poor outcomes. For example, poor medication adherence could lead to treatment failure. Continued IDU (without safe injection practices) could lead to re-infection after treatment.
Aside from these concerns, some insurance companies also require pre-treatment screening for drug and alcohol use. These companies may deny medication to people with current or recent use. However, there are no data to support this practice. Screening for drug use is not a reliable method of determining who will complete treatment successfully. Instead, these practices create barriers, increase health care costs, and exclude a population who could benefit from access to treatment. According to current practice guidelines, we should abandon all pre-treatment drug and alcohol screening.
Aside from these outside barriers, there are also internal barriers that can pose a challenge. Recently, I assisted a patient applying for insurance coverage for HCV treatment. The medication was approved, and he did not have a copay. We reviewed goals of therapy, administration, adherence, potential side effects, and pharmacy procedures. He expressed no concerns and there were no known issues to address.
A few weeks went by and when it would have been time for his first refill, he was unreachable by phone. Eventually, I discovered he had not started treatment. He wasn’t answering his phone because he was afraid he would be in trouble. He admitted to ongoing IDU and thought it would be best to wait until later because “there was no point.” For him, public stigma related to IDU had turned into self-stigma. He did not believe he deserved treatment because he believed he was “doomed” to re-infection even if treatment was successful. Additionally, he had no symptoms of HCV disease, so immediate treatment did not seem to him to be a priority.
Benefits of HCV treatment in PWID
Of course, there is a point to treating HCV in PWID. First, the longer HCV goes untreated, the greater the risk of permanent liver damage. Other personal risk factors can accelerate this damage (such as poor diet, alcohol use, HIV co-infection, genetics, and type of infection), so even if you have no symptoms, treatment is beneficial. Second, PWID can be successfully treated. IDU does not directly correlate with poor medication adherence or treatment failure, so this should not be used as a reason to deny treatment. Finally, after a person is cured of HCV, they can no longer transmit the virus to others. Thus, treating HCV in PWID also provides public health benefits.
Side note: Keep in mind, there are valid reasons to delay HCV treatment (these include major drug interactions and untreated HIV infection), so be sure to discuss this with your provider. If treatment needs to be delayed for any reason, it is important to stay engaged in care. Your provider can monitor disease progression and recommend treatment when appropriate.
New data supporting HCV treatment in PWID
In October 2020, Clinical Infectious Diseases published results from ANCHOR, a single-study evaluating treatment of HCV in PWID with chronic HCV, OUD (opioid use disorder), and IDU. The study was done by researchers at the University of Maryland. It took place at a harm reduction organization’s drop-in center in Washington, D.C. In the study, 100 people living with HCV infection, opioid use disorder, and ongoing injection drug use were treated for HCV with direct-acting antivirals (DAAs). Study participants were mostly male (76%) and Black (93%). Of the participants, 58% injected opioids daily. All participants were prescribed 12 weeks of sofosbuvir/velpatasvir (brand name Epclusa) to treat HCV. They were all also offered opioid agonist therapy (OAT).
Opioid agonists (i.e., buprenorphine, methadone) are used to treat opioid use disorder. These therapies work by activating the same receptors as opioids, but to a lesser extent. This helps to reduce both cravings and withdrawal symptoms. Researchers wanted to offer OAT to help reduce risk for study participants, as OAT has been shown to reduce IDU, opioid use, infections, and death from overdose.
The purpose of the study was to find out if PWID could successfully be treated with DAAs. Researchers also wanted to know what percentage of participants would start and continue OAT therapy and determine what factors would affect treatment outcomes. Researchers looked at medication adherence rates, treatment completion rates, and cure or sustained virologic response (SVR) rates.
In the study, 82 of the 100 participants were cured despite imperfect adherence to medication. There were some known interruptions in therapy and many completed treatment more than one week late. In the study, neither on-treatment drug use nor imperfect adherence were associated with treatment failure. However, continuing OAT and completing two or more bottles of sofosbuvir/velpatasvir were associated with achieving cure.
Researchers concluded that offering OAT with HCV treatment in PWID and opioid use disorder can result in high SVR rates while also reducing risks associated with drug use. Further, people who inject drugs can be successfully treated for HCV at rates comparable to those who do not use drugs, even if adherence is not perfect.
You can read the full article, “Concurrent Initiation of Hepatitis C and Opioid Use Disorder Treatment in People Who Inject Drugs,” at ncbi.nlm.nih.gov/pmc/articles/PMC7755091/?report=reader.
As stated by current hepatitis C guidelines (hcvguidelines.org) from the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), active or recent drug use or a concern for re-infection is not a reason in itself to deny HCV treatment. HCV treatment for PWID, in combination with harm reduction services (including syringe exchange programs, routine HCV testing, condom distribution, opioid agonist/antagonist therapies) will be vital to the elimination of HCV.
Kaitlyn Jarrell, PharmD is an HCV clinical pharmacist at Indiana University Health (IU Health) in Indianapolis. She works closely with providers specializing in Hepatology and Infectious Diseases within the IU Health system (both in downtown Indy as well as smaller sites across the state) to assist with insurance approvals, patient education, adherence monitoring, and lab follow-up. In addition, she works with the physicians at IU Health Physicians Infectious Disease, primarily assisting with the management of care in patients living with HIV. Dr. Jarrell graduated from the University of Mississippi (Ole Miss) in 2018. After pharmacy school, she completed a two-year residency at IU Health, with her second year specializing in pharmacy administration. She is credentialed as a board-certified Pharmacotherapy Specialist through the Board of Pharmacy Specialties as well as an HIV Specialist through the American Academy of HIV Medicine.
COVID-19 and viral hepatitis
It seems that treatment of COVID-19 in people with viral hepatitis is no different than for anyone else—unless they have cirrhosis.
“People with underlying cirrhosis of the liver, including those caused by viral hepatitis, may have the potential for a higher risk of developing severe COVID-19 illness and/or more problems from their existing liver disease if they get a COVID-19 infection, with prolonged hospitalization and increased mortality,” writes the American Association for the Study of Liver Diseases (AASLD) in an educational flyer. “These patients need to take careful precautions to avoid COVID-19 infection. COVID-19 may affect the processes and procedures for screening, diagnosis, and treatment of viral hepatitis.”
That said, there’s actually not much known about the impact of COVID-19 on people living with hepatitis B or C, AASLD continued.
Stay on your medications, including those for HBV or HCV, unless your doctor tells you otherwise, both AASLD and the U.S. Centers for Disease Control and Prevention (CDC) say. And get vaccinated against COVID-19, hepatitis A, and hep B as well—this last includes babies.
And CDC wrote this in a separate announcement about substance use: “Why is there an increased risk of COVID-19 infection and complications for individuals with an addiction? Chronic substance use can harm or weaken the body, including the immune system, and make an individual more vulnerable to infection. The effect of certain types of substances used may present greater risks as well, particularly opioids, alcohol, nicotine, and methamphetamines present greater risks for patients to develop severe illness from COVID-19.”
Read the four-page flyer from AASLD at aasld.org/sites/default/files/2020-10/COVID19-Flyer-ViralHepatitis.pdf. Read the CDC Q&A at cdc.gov/coronavirus/2019-ncov/need-extra-precautions/liver-disease.html.