Accessible care achieves higher hepatitis C cure rate in people who inject drugs

Hepatitis C care located within a needle and syringe programme in New York achieved a three times higher cure rate than referral to a patient navigator and linkage to medical care at a harm reduction programme or clinic, a randomised trial in New York City has found.

Improving the uptake of hepatitis C care among people who inject drugs is essential for achieving the elimination of hepatitis C, especially in countries where the majority of people with hepatitis C are current drug users.

People who inject drugs experience numerous barriers to care. As well as dealing with competing priorities including food, housing, addiction and criminalisation, people who inject drugs also face barriers to obtaining care due to stigma and requirements for abstinence from drugs before initiating treatment.

Although drugs services may offer hepatitis C testing, people who are diagnosed with hepatitis C are usually referred to other services for treatment. As a consequence, linkage to care is often sub-optimal.

Offering care in services with low barriers to entry, where service users can walk in without an appointment and also obtain methadone maintenance, has been shown to encourage the uptake of treatment.

The study, carried out at the Lower East Side Harm Reduction Center in Manhattan, was designed to test whether offering hepatitis C treatment through a ‘low threshold’ drugs service resulted in better cure rates than linking people to existing hepatitis C care in medical facilities.

People were eligible to join the study if they had injected drugs for at least one year, had injected drugs within the previous 90 days and had a detectable hepatitis C viral load. The study excluded people already engaged in hepatitis C care, people with decompensated cirrhosis or liver cancer, and pregnant women.

The study recruited 167 people with hepatitis C between 2017 and 2020 and randomised them to receive hepatitis C care at Lower East Side Harm Reduction Center or referred them to a standard-care arm in which a treatment navigator supported them to obtain care through clinical services in New York City.

The study population had a median age of 42 years, just over three-quarters (77%) were male, 58% were Hispanic and 32% were White. Seven per cent were living with HIV. Thirty per cent were not receiving opioid substitution treatment, 64% received methadone and 6% received buprenorphine.

Consistent with the proportion not receiving opioid substitution treatment, 39% reported daily injecting during the previous month. Forty-seven per cent were injecting heroin, 27% cocaine and 24% were injecting cocaine and heroin together (a speedball). Eighty per cent had visited a needle and syringe programme during the past 90 days.

The majority received treatment with glecapravir/pibrentasvir (Maviret) (71%). Twelve per cent received sofosbuvir/velpatasvir (Epclusa), 8% received grazoprevir/elbasvir (Zepatier), 5% received sofosbuvir/ledipasvir (Harvoni) and 3% received sofosbuvir/velpatasvir/voxilaprevir (Vosevi).

People in the accessible-care arm were significantly more likely to achieve a sustained virological response (cure) than people in the standard-care arm (67% vs 22%), due to a much higher rate of linkage to care. People in the accessible-care arm were more likely to be referred to a hepatitis C clinician (92% vs 44%), more likely to attend the first clinical visit (86% vs 37%), to complete baseline laboratory testing (86% vs 31%) and start treatment (78% vs 26%).

The rate of cure in the accessible-treatment arm was not affected by age, sex, ethnicity, homelessness, daily injecting or prior hepatitis C treatment. The rate of treatment failure did not differ significantly between the two study arms (10% vs 9%).

The study investigators point out that the cure rate was roughly three times higher in the accessible-care arm despite the fact that people in the standard-care arm had the support of a patient navigator who could accompany them to clinic visits, work to resolve insurance issues and support adherence. The rate of cure in the standard-care arm was higher than in programmes for people with inject drugs outside New York City that lack a patient navigator.

The investigators were surprised to learn that being a previous user of the needle and syringe programme did not affect whether people in the accessible-care arm started treatment or not. Only 30% of participants in the accessible-care arm were recruited at the study site; the remainder were recruited at other needle and syringe programmes or through study participants or peers.

They say that providing a low-threshold non-judgemental environment for people to encounter hepatitis C testing and treatment may be more important than providing a familiar environment.

They also point out that 70% of participants were already receiving opioid substitution treatment but had not yet been cured for hepatitis C, suggesting a failure to engage opioid substitution treatment recipients in hepatitis C care.