Offering hepatitis C treatment and opioid substitution therapy with buprenorphine at the same location can help increase adherence and reduce harms associated with injection drug use, according to findings from the ANCHOR study presented at the 2018 International Liver Congress in Paris.
Hepatitis C virus (HCV) is easily transmitted through shared syringes and other drug injection equipment, and current and former injection drug users have high rates of infection.
Many providers have traditionally considered people who inject drugs to be poor candidates for hepatitis C treatment. What’s more, ongoing injection drug use can result in HCV re-infection after being cured. The availability of highly effective and well-tolerated direct-acting antivirals (DAAs) that can cure most people in 8 to 12 weeks leaves little justification for withholding treatment from this highly affected population. In fact, providing hepatitis C treatment may offer an opportunity to help people address their drug use.
Elana Rosenthal of the University of Maryland School of Medicine presented results from ANCHOR, a study of hepatitis C treatment for people who inject drugs conducted at an urban harm reduction centre in Washington, DC. The centre employs community health workers and provides transportation as needed.
The study enrolled 90 participants with an opioid use disorder who had injected opioids within the past 3 months and had not been previously treated with DAAs.
About three-quarters were men, more than 90% were black and the median age was 56 years; a quarter had compensated liver cirrhosis. Less than 5% had HIV co-infection. Sixty per cent said they injected opioids at least once a day, and more than a quarter reported receptive sharing of injection equipment (meaning someone else used it first). Around 80% were enrolled in syringe exchange programmes. Half reported unstable housing and more than 90% had a history of incarceration.
Participants started hepatitis C treatment using sofosbuvir/velpatasvir (Epclusa), a one-pill, once-daily regimen that is effective against all genotypes of HCV. They received a month’s worth of pills at baseline and at weeks 4 and 8, with end-of-treatment follow-up at week 12 and post-treatment follow-up at week 24; follow-up will continue through week 96 to assess long-term outcomes.
While undergoing hepatitis C therapy, participants were offered the opportunity to start medication-assisted treatment for addiction using buprenorphine, a partial opioid agonist that relieves withdrawal symptoms and reduces drug cravings. Sofosbuvir/velpatasvir and buprenorphine were given at the same location by the same medical provider.
About a third (30%) were already on opioid substitution therapy at screening. All of the rest expressed an interest in buprenorphine and 39 people (43%) started using it; 22 (24%) did not use any medication-assisted treatment. (Those who switched from methadone to buprenorphine were not included in this analysis.)
At the time of the analysis, 55 participants had reached 24 weeks of post-treatment follow-up. Among the 46 people with available viral load data, 91% achieved sustained virological response, or continued undetectable HCV RNA (SVR24), which is considered a cure. Looking at all 55 people, 76% achieved SVR24, 13% missed the study visit, 7% still had detectable HCV, 2% had died and 2% were still awaiting results.
People who were either on opioid substitution therapy at baseline or who started buprenorphine were significantly more likely to attend clinic visits than those not on any medication-assisted treatment. Attendance at week 4 was 95%, 89% and 71%, respectively. Attendance was lowest at week 12 (86%, 81% and 40%, respectively), but increased again by week 24 (88%, 86% and 67%).
Participants who were still on buprenorphine at week 4 were more likely to receive their second bottle of sofosbuvir/velpatasvir than those who were never or no longer on opioid substitution therapy (100% vs 82%). At 8 weeks, 96% of those who were on opioid substitution therapy at baseline, 90% of those who started buprenorphine and 87% who were not on medication-assisted treatment picked up their third bottle of sofosbuvir/velpatasvir.
Participants who started buprenorphine during hepatitis C treatment showed a significant decline in behaviours associated with HIV and HCV transmission risk from baseline to week 4, week 12 and week 24. No significant change was observed for people who were already on opioid substitution therapy at baseline. Those who were not on any medication-assisted treatment also saw a decline, but this did not reach statistical significance.
“Preliminary results of the ANCHOR study support that active PWID [people who inject drugs] not on medication-assisted treatment can be successfully initiated on buprenorphine during the course of HCV treatment,” the researchers concluded. “HCV treatment may provide a critical opportunity to not only cure HCV, but simultaneously prevent re-infection and treat opioid use disorder in high-risk, marginalized PWID.”
By Liz Highleyman
Rosenthal E et al. Collocation of buprenorphine with HCV treatment to improve adherence and reduce harm in PWID with HCV: Preliminary data from the ANCHOR study. The International Liver Congress, Paris, abstract PS-092, 2018. Journal of Hepatology 68:S51, 2018.