Hepatitis C Prevention and Management for People Who Inject Drugs

People who inject drugs can benefit from hepatitis C prevention efforts and antiviral treatment, but comprehensive programs may be needed to help overcome a variety of challenges, according to a special supplement of Clinical Infectious Diseases entitled "Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs: Moving the Agenda Forward." The International Network on Hepatitis in Substance Users is holding its biennial symposium this week in Munich.

"HCV treatment is safe and effective among people who inject drugs [PWID], and international guidelines encourage HCV treatment in this group, but HCV treatment uptake remains low among PWID, mainly due to patient-, practitioner- and systems-related barriers to care," wrote guest editors Jason Grebely, Philip Bruggmann, Markus Backmund, and Gregory Dore in an editorial overview. "However, strategies have emerged to improve the prevention and management of HCV infection among PWID."

The editors noted that the International Network on Hepatitis in Substance Users (INHSU) was established to promote dissemination of knowledge in the field of viral hepatitis among PWID. The group puts on an International Symposium on Hepatitis Care in Substance Users every 2 years, with this year's meeting taking place September 5-6.

Despite guidelines encouraging treatment, many clinicians and people who use drugs have been hesitant about interferon-based therapy for a variety of reasons, including concerns about poor adherence, fears about worsening depression (a common side effect of interferon), and the need to inject interferon, which could be a trigger for recovering users.

The advent of the first direct-acting antiviral agents (DAAs) in 2011 ushered in a new era of hepatitis C treatment. Adding boceprevir (Victrelis) or telaprevir (Incivek or Incivo) to pegylated interferon plus ribavirin can shorten treatment and raise the likelihood of a sustained cure, but the new drugs bring added side effects.

While people with advanced liver disease may not be able to wait, many patients and providers are looking ahead to all-oral regimens using new DAAs that are much better tolerated and offer a higher cure rate in less time without the drawbacks of interferon. The first of these next-generation agents -- simeprevir (TMC435) and sofosbuvir (GS-7977) -- are expected to be approved by the end of 2013 or early 2014.

Interferon-free therapy should be a boon for PWID -- like all people with hepatitis C -- helping overcome some of the barriers that keep people from getting the treatment they need.

As the 2013 symposium gets underway, the Clinical Infectious Diseases supplement presents original research from the previous meeting, highlighting advances in the areas of the hepatitis C epidemiology and natural history among PWID, clinical applications of basic science research, management of medical co-morbidities, and social science and community-based perspectives.

The availability of simple, well-tolerated, and highly effective interferon-free direct-acting antivirals will facilitate engagement among PWID, but research on strategies to enhance HCV screening and assessment is still needed," the editors concluded. "The evaluation of strategies to enhance adherence and therapy outcomes (e.g., directly observed therapy, medication reminders, adherence education, peer support) should also be a research priority."

First PWID Recommendations

At the 2011 symposium a panel of experts was convened by INHSU in collaboration with the European Liver Patients Association (ELPA) to develop the first-ever international recommendations for the management of hepatitis C among PWID, which are included in the supplement.

The new recommendations cover hepatitis C prevention, effects of drugs on the liver, non-invasive fibrosis assessment, pre-therapeutic assessment, indications for treatment, use of pegylated interferon and currently approved DAAs, the impact of drug use on treatment adherence and likelihood of achieving sustained virological response (SVR), the impact of mental health on adherence and SVR, treatment management, HCV re-infection following successful therapy, treatment of acute hepatitis C, HIV/HCV coinfection, hepatitis B coinfection, and liver transplantation.

"Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed," the panel concluded. "These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment."

However, "many studies performed among PWID to date are limited, given retrospective designs, small sample sizes, and lack of randomized controlled trial design," they continued. "Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new DAAs become available. This will be crucial in the efforts to stem the burden of HCV-related liver disease worldwide." 

HCV Prevention for Young PWID

One interesting study in the supplement, by Kimberly Page from the University of California at San Francisco (UCSF) and colleagues, looked at hepatitis C prevention strategies for young drug injectors. 

Two notable findings were that HCV can spread via drug containers, filters, and rinse water as well as needles and syringes, and that attempting to quit or "taking breaks" from drug use predicts eventual success.

Below is an edited excerpt from a UCSF news release describing the research.

Six Recommended Measures to Prevent Hepatitis C for Young Injection-Drug Users

July 24, 2013 -- by Jeff Sheehy -- UC San Francisco researchers are recommending a combination of six comprehensive measures to prevent the spread of hepatitis C, in an effort to address the estimated 31,000 young people who may be newly infected each year in the United States due to injection-drug use.

The measures, which stem from a 16-year UCSF research project with injection-drug users, known as the "U Find Out" or UFO Study, build upon the successes of clean syringe programs and similar efforts, while recommending greater focus on the social issues behind drug use and further integration of the multiple approaches to combating hepatitis C.

In February, the U.S. Department of Health and Human Services (HHS) noted the rising epidemic of hepatitis C virus among young people aged 15-30 who inject drugs, calling attention to an increasingly serious issue nationwide.

While data on hepatitis C are limited, the HHS estimates that as many as 3.9 million people in the United States are living with a chronic form of the disease, which the researchers said is at least 10 times more infectious than HIV. In 2007, the number of U.S. deaths associated with hepatitis C surpassed those from HIV for the first time.

"Based on our UFO Study here in San Francisco, we have accumulated data that identify key strategies that, when scaled up, could substantially reduce the rate of new hepatitis C infections among young people who inject drugs," said the study’s lead investigator, Kimberly Page, PhD, MPH, a professor in the UCSF Department of Epidemiology and Biostatistics, and in UCSF Global Health Sciences.

The research team examined several data sources to arrive at the new estimate of 31,000 new cases per year and identified six areas where prevention efforts should be focused. Findings appear online July 24 in a special supplement titled, "Prevention and Management of Hepatitis C Virus among People Who Inject Drugs: Moving the Agenda Forward," in the journal Clinical Infectious Diseases. The publication coincides with World Hepatitis Week, July 21 to 28.

Beyond Syringe Exchange Programs

First, while syringe-exchange programs have long been recognized as an absolutely essential element in disease prevention, giving injectors access to clean needles and syringes, the UFO Study team discovered that up to 40 percent of infections occurred from exposures to shared drug preparation containers, filters and rinse water.

"The hepatitis C virus lives a long time on surfaces and can easily contaminate various types of injecting equipment, so while expanding needle exchanges throughout the country is essential, one of our critical recommendations is that existing and newly established exchanges provide clean ancillary equipment along with needles and syringes," said Page.

Additional strategies identified in the paper include hepatitis C virus screening, testing and counseling; targeting interventions to address the social and relational contexts of injecting; injection cessation interventions to reduce risks of exposure; development of models to guide roll out of new hepatitis C treatments and vaccines; and the implementation of robust, scaled interventions in combination to synergize the effectiveness of individual interventions.

"A new rapid test for hepatitis C has become available that can be delivered at the point of care with results in 20 minutes, so making that widely available can significantly improve screening, testing and counseling," said Page. "Also, our research identified the value of 'taking breaks' for both reducing the risks of exposure to the virus and helping end injection drug use."

The UFO Study looked at the behaviors associated with attempts by injectors to complete various injection cessation programs, such as 12-step or opiate substitution programs. While in these programs, exposure risks disappeared.

However, while injectors frequently fail cessation programs, the UFO Study showed that the more injectors try to quit, or "take breaks" from drugs, the more likely they eventually are to succeed. That new data could inform how these and other treatment programs handle relapses in the future.

"Often these programs are very unforgiving and relapses can lead to permanent bans," Page said. "This is likely not the best tactic for reducing disease exposure risks and also may not be optimal for helping injectors end injection drug use."

Co-authors include Meghan Morris and Judith A. Hahn, PhD, from UCSF; Lisa Maher from the Kirby Institute in Sydney, Australia; and Maria Prins from the Public Health Service in Amsterdam, The Netherlands.

The UFO Study is funded by the U.S. National Institute on Drug Abuse and the Australian Government Department of Health and Ageing.

9/4/13

References

J Grebely, P Bruggmann, M Backmund, GJ Dore, et al. Moving the Agenda Forward: The Prevention and Management of Hepatitis C Virus Infection Among People Who Inject Drugs. Clinical Infectious Diseases 57(suppl 2):S29-S31. August 15, 2013.

G Robaeys, J Grebely, S Mauss, et al. on behalf of the International Network on Hepatitis in Substance Users. Recommendations for the Management of Hepatitis C Virus Infection Among People Who Inject Drugs. Clinical Infectious Diseases 57(suppl 2):S129-S137. August 15, 2013.

K Page, MD Morris, JA Hahn, et al. Injection Drug Use and Hepatitis C Virus Infection in Young Adult Injectors: Using Evidence to Inform Comprehensive Prevention. Clinical Infectious Diseases 57 (suppl 2):S32-S38. August 15, 2013.

Other Source

J Sheehy, UCSF. Six Recommended Measures to Prevent Hepatitis C for Young Injection-Drug Users. News release. July 24, 2013.