Case Series of Integrated Care for Patients With HCV, Substance Use Disorders, and Other Adverse Circumstances

Prior to the advent of direct acting antivirals (DAAs), standard of care for the treatment of hepatitis C (HCV) was the use of interferon-based regimens, which had a prolonged duration, significant treatment-related adverse effects, and only about a 50% chance of cure. Up until 2009, American Association for the Study of Liver Diseases guidelines suggested that patients who injected drugs (PWID) were not eligible for HCV treatment. DAAs are associated with much shorter treatment duration (8–12 weeks in many cases), improved side effect profile, and cure rates exceeding 90% compared with interferon treatment. Researchers in France assessed the factors associated with a sustained virologic response (SVR) among patients undergoing DAA treatment at an HCV clinic who were also followed in addiction treatment settings through the use of a multidisciplinary team meeting, including hepatologists, addiction medicine providers, pharmacists, and a specialized nurse. They focused on 50 patients with substance use disorders (84% male, mean age 46 years) who had experienced a failure of referral to a specialized team or a decision by a specialized team not to initiate DAA treatment immediately due to ongoing substance use, significant psychiatric disorder, homelessness/precarious housing, or a combination of these factors.

• HCV genotypes were: 1 (n=21), 2 (n=4), 3 (n=18), 4 (n=6), or 6 (n=1). Most patients were HCV treatment-naïve (n=38).
• Five patients also had either HIV (n=4) or hepatitis B (n=1); 28 had evidence of cirrhosis on FibroScan (>12.5 kPa); 34 were receiving opioid agonist treatment.
• Psychiatric disease, illicit drug use, unemployment, and homelessness/precarious housing were common. Forty-five patients (90%) achieved SVR, 2 were lost to follow-up, and 3 did not achieve an SVR.
• Due to small sample size there was no relationship between specific demographic, clinical, socioeconomic, or psychological factors and achieving SVR.

Comments: This study adds to the growing body of literature that PWIDs treated with DAAs for HCV have outcomes similar to other populations. It is notable that the team caring for patients in this study included a coordinated multidisciplinary team, which may limit generalizability.

Jeanette M. Tetrault, MD

Reference: Trabut JB, Barrault C, Charlot H, et al. Integrated care for the use of direct-acting antivirals in patients with chronic hepatitis C and substance use disorder. J Addict Med. 2018;12(5):346–352.