This study found that:
- For people with hepatitis C virus (HCV) who inject drugs, offering buprenorphine treatment for opioid use disorder at the same location as HCV treatment resulted in high rates of buprenorphine initiation.
- People who started and maintained buprenorphine during HCV treatment experienced numerous clinical benefits compared with those who stopped or never initiated buprenorphine therapy.
- Ongoing drug use or imperfect treatment adherence did not significantly affect HCV cure rates.
Many people who inject drugs (PWID) also have hepatitis C virus (HCV); however, they often face significant challenges when seeking access to HCV treatment (i.e., treatment with antiviral medications). Many insurance companies continue to deny access to HCV treatment to people with substance use disorders unless they are abstinent or, in some cases, are engaged in a formal drug treatment program. Even if insurance companies are willing to cover treatment, providers are often reluctant to offer HCV treatment to PWID because they are concerned about non-adherence to the treatment regimen.
Dr. Elana S. Rosenthal from the Institute of Human Virology at the University of Maryland School of Medicine and colleagues from other institutions and organizations recently demonstrated, however, that offering treatment services for HCV and opioid use disorder (OUD) in the same facility can yield numerous clinical benefits for PWID. “In our clinical practice, we were seeing patients who had ongoing injection drug use but were very eager to access HCV treatment,” explains Dr. Rosenthal. She adds, “We believed that excluding them from treatment was unjust and discriminatory, and that denying HCV treatment to people who inject drugs would not only prevent them from getting potentially lifesaving therapy but could also alienate them from engaging in further medical care.”
The team’s study, A Novel Model of Hepatitis C Treatment As an Anchor to Prevent HIV, Initiate Opioid Agonist Therapy, and Reduce Risky Behavior (ANCHOR), was designed to investigate whether HCV treatment could serve as an opportunity to improve engagement in care and enhance initiation of medication therapy for OUD in this patient population. The ANCHOR trial included 100 participants who had HCV and OUD and currently engaged in injection drug use. All participants received sofosbuvir-velpatasvir therapy for 12 weeks to treat their HCV and were also offered buprenorphine throughout the study.
Offering HCV and OUD Treatment Together Improves HCV and Opioid Use Outcomes
Of participants who did not already use medication treatment for OUD when starting HCV therapy, 79 percent initiated opioid agonist therapy with buprenorphine. The researchers identified numerous benefits when HCV and buprenorphine treatment took place at the same location (see Figure). Compared with participants who never initiated buprenorphine or discontinued it during the study, those who started and remained on buprenorphine while receiving HCV therapy:
- Had significantly higher HCV cure rates.
- Had significantly greater declines in opioid-positive urine screens over the course of the study.
- Experienced significantly fewer overdoses over the study period.
- Showed significant reductions in HIV risk-taking behaviors over the study period.
The researchers also observed that neither ongoing drug use nor imperfect adherence to the daily treatment regimen significantly affected HCV cure rates. Therefore, Dr. Rosenthal concludes, “Ongoing drug use, or concerns about adherence, should not be used as a justification to deny patients access to HCV treatment.”
The study provides strong evidence that all people who use drugs should have access to HCV treatment, regardless of ongoing drug use. Treating and curing HCV in PWID is critical for interrupting HCV transmission and achieving HCV elimination. However, to optimize care in PWID, healthcare providers must address the underlying cause of HCV—the OUD—by offering medications for OUD, such as buprenorphine. This can be facilitated by offering such therapy at the same locations as HCV treatment.
Dr. Rosenthal says, “The ANCHOR study demonstrates that a model of care collocating treatment of HCV and OUD results not only in high rates of HCV cure, but in uptake and retention of OUD treatment, as well. This model can be replicated in order to reduce HCV transmission and improve the overall health of people who use drugs."
This work was supported by NIDA grant DA043396-01A1.
- Text Description of Figure
The figure illustrates the effects of offering OUD treatment at the same location as HCV treatment. Panel A on the top left shows the effect on HCV presence. The vertical y-axis indicates the percentage of participants with undetectable HCV levels at 12 weeks after HCV treatment on a scale from 0 to 100%. Among all 100 patients (first, purple bar), 82% had undetectable HCV; among the 31 patients who received OAT with buprenorphine throughout the study (second, blue bar) 90% had undetectable HCV; among the 37 patients who started and retained OAT during the study (third, green bar), 92% had undetectable HCV; among the 16 patients who started OAT but stopped it again during the study (fourth, yellow bar); 63% had undetectable HCV; among the 14 patients who never received OAT (fifth, brown bar), 64% had undetectable HCV; and among the 2 patients who previously had OAT but stopped it during the study (sixth, red bar), 50% had undetectable HCV. The difference between those who started and retained OAT and those who started and stopped OAT or never received OAT was statistically significant as indicated by the horizontal black lines above the third and fourth and the third and fifth bars, respectively.
Panel B on the top right shows the effect on opioid use. The vertical y-axis indicates the percentage of participants who had an opioid-positive urine screen at the respective study visits on a scale from 0 to 100%. For all patients (first, purple set of bars), the percentage declined from about 80% at baseline to about 77% at 4 weeks, about 70% at 12 weeks, and about 68% at 24 weeks. Among those who received OAT throughout the study (second, blue set of bars), the percentage declined from about 65% at baseline to about 56% at 4 weeks, increased to about 76% at 12 weeks, and then declined to about 68% at 24 weeks. Among those who began and retained OAT during the study (third, green set of bars), the percentage was about 80% at baseline, increased to about 82% at 4 weeks, and then declined to about 58% at 12 weeks and 56% at 24 weeks; the difference between baseline and 24 weeks was statistically significant as indicated by the horizontal black line above the bars. Among those who began and stopped OAT during the study (fourth, yellow set of bars), the percentage was about 86% both at baseline and at 4 weeks, then declined to about 70% at 12 weeks and about 65% at 24 weeks. Among those who never received OAT (fifth, brown set of bars), the percentage was 100% at baseline, declined to about 83% at 4 weeks, and then increased to about 90% at 12 weeks and 100% at 24 weeks.
Panel C shows the effects of concurrent HCV and OUD treatment on HIV risk-taking behavior. The horizontal x-axis shows the time from 0 weeks to 24 weeks. The vertical y-axis shows the HIV risk-taking behavior score on a scale from 0 to 8. For those who always were on OAT (blue dotted line), the HIV risk-taking behavior score was about 5.3 at 0 weeks, about 3.5 at 4 weeks, about 3.7 at 12 weeks, and about 4.5 at 24 weeks. For those who started and retained OAT throughout the study (solid green line), the HIV risk-taking behavior score was about 7 at 0 weeks, about 4 at 4 weeks, about 3 at 12 weeks, and about 2.8 at 24 weeks. For those who started and stopped OAT during the study (yellow dotted line), the HIV risk-taking behavior score was about 5 at 0 weeks, about 4.8 at 4 weeks, about 3 at 12 weeks, and about 4 at 24 weeks. For those who never received OAT (brown dotted line), the HIV risk-behavior score was about 7.6 at 0 weeks, about 5.3 at 4 weeks, about 5.7 at12 weeks, and about 5.6 at 24 weeks.
Rosenthal, E.S., Silk, R., Mathur, P., et al. Concurrent initiation of hepatitis C and opioid use disorder treatment in people who inject drugs. Clinical Infectious Diseases 71(7):1715–1722, 2020.