Introduction
People who use drugs (PWUD) are an important target population for hepatitis C virus (HCV) elimination in the World Health Organization (WHO) goals, because the PWUD population contains one of the largest clusters of residual HCV infections. Case-finding and treatment of these patients in hospitals is considered a challenge, while low threshold on-site screening and therapy in addiction care might facilitate viral elimination. We studied implementation of a decentralized PWUD-HCV care model, by exploring 1) viral elimination rates, and 2) facilitators and barriers for implementation.
Aims & Methods
In a multicenter mixed-method study in addiction care centers in the Netherlands we examined HCV-related outcomes in PWUD receiving HCV treatment within addiction care. The primary outcome was viral elimination, defined as percentage of identified HCV positive patients achieving sustained virologic response (SVR). Using semi-structured interviews barriers and facilitators for implementation were identified among health professionals and policy makers of addiction care and hospitals.
Results
We found 33 PWUD HCV RNA positive. Four patients were referred to the hospital for treatment due to hepatitis B virus or HIV co-infection or other reasons. Two patients currently receive treatment, three patients were not yet fit for treatment and two were lost to follow-up before treatment could be started. On-site treatment was initiated in 22 patients. Of these patients 91% was male, mean age was 50 years (SD=13) and 36% was born in the Netherlands. All patients completed treatment with glecaprevir/pibrentasvir (n=9) or sofosbuvir/velpatasvir (n=13). All on-site and hospital treated patients reached SVR and there were no reinfections. The viral elimination rate was 79% (26/33). Themes on facilitators and barriers for implementation collected in the interviews are shown in the table.
| Theme | Facilitators | Barriers |
Care chain agreements
| - Positive hospital attitudes and willingness
- Low-threshold communication channel
| - Lack of support in some hospitals
- Halt of previous infectious disease collaboration
|
Expertise
| - Most felt comfortable enough with their knowledge
- Not much expertise needed in most cases
| |
| Nurse as the mediator | - Schooled in motivational interviewing
- Most intensive relationship with patients
| |
| Perceived problem scope | - Establishing a network is also relevant to detect other infectious diseases
| - HCV is perceived as a closed chapter
- Challenging to gain experience in managing the disease
|
Treatment outcomes
| - Elimination is beneficial even if not all consequences are treated
- HCV treatment can motivate patients to change life
- Treatment can also enhance addiction treatment
| |
Patient profile
| | - Difficult to plan and keep appointments
- More psychological comorbidity in patients with addiction.
- Intellectual disabilities are more common
|
Stigma
| - Addiction care more accepting and understanding
| - Low-threshold treatment may lead to an underestimation of the severity
- Patients feel ashamed about having infectious disease
|
Hierarchical decision making
| - Variation in expertise and opinions among managements where HCV care should be centered
| - Variation in expertise and opinions among managements where HCV care should be centered
- Communication from management is poor
- Bureaucracy and slow decision-making
|
Conclusion
This study shows the high viral elimination (79%) of decentralized care of HCV infections within addiction care and provides insight in facilitators and barriers for on-site HCV treatment. Based on these findings we recommend implementation and maintenance of decentralized HCV-addiction care models worldwide. This will lead to HCV elimination scaling-up in the Netherlands and abroad, furthering WHO goals.
References
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Oru, E., Trickey, A., Shirali, R., Kanters, S., & Easterbrook, P. (2021). Decentralisation, integration, and task-shifting in hepatitis C virus infection testing and treatment: a global systematic review and meta-analysis. The Lancet Global Health, 9(4), e431-e445. https://doi.org/10.1016/s2214-109x(20)30505-2
Von den Hoff, D. W., Berden, F. A. C., Atsma, F., Schellekens, A. F. A., & Drenth, J. P. H. (2022). Against All Odds? Addiction History Associated with Better Viral Hepatitis Care: A Dutch Nationwide Claims Data Study. J Clin Med, 11(4). https://doi.org/10.3390/jcm11041146
European Association for the Study of the Liver, e. e. e., Clinical Practice Guidelines Panel, C., representative, E. G. B., & Panel, m. (2020). EASL recommendations on treatment of hepatitis C: Final update of the series(). J Hepatol, 73(5), 1170-1218. https://doi.org/10.1016/j.jhep.2020.08.018
Disclosure
Daan Von den Hoff and Joost Drenth declare receipt of funds from Abbvie and Gilead; the other authors have nothing to declare.
