- A nurse-led project co-housed hepatitis C testing and treatment services at an addiction centre
- Creating a ‘one-stop’ health service resulted in 67% of eligible patients receiving treatment
- At the end of the study, 97% of treated patients were cured of hepatitis C
Prior to 2014, treatment for chronic hepatitis C virus infection (HCV) involved regular injections of interferon, sometimes in combination with other drugs, for many months. Interferon caused a lot of side effects, some of which could be deeply distressing. Furthermore, interferon-based therapies were not highly effective. Thus, several factors—the need for regular injections, harsh side effects and modest efficacy—acted as barriers to treatment.
In 2014, a group of powerful all-oral direct-acting antivirals (DAAs) gradually became available and subsidized in Canada and other high-income countries. DAAs are designed to attack HCV-infected cells. In clinical trials, these drugs cured at least 95% of participants. What’s more, DAAs are much safer than interferon-based therapy. Given these attributes of DAAs, the World Health Organization (WHO) has encouraged countries and regions to help eliminate HCV as a public health issue by 2030.
A shift in where care is accessed
When DAAs became available, major hospitals and clinics had many people with HCV waiting to be cured. These people knew their HCV infection status and received DAA therapy soon after access became subsidized. Although many people have since been cured, a significant proportion of people with HCV in Canada (and some other high-income countries) today are not aware of their HCV infection status. In part, this population often must deal with other issues—such as periods of homelessness; untreated, undiagnosed or poorly managed mental health conditions; food insecurity; violence, and substance use disorder. These other issues compete for attention in people with HCV and make it more difficult for them to access and engage in HCV care.
A team of researchers in Brighton, England, established a project: a decentralized, nurse-run HCV health service housed in a centre that provided help for people with substance use disorder. In the healthcare field, sometimes projects that do not have dedicated funding receive other sources of funding when they are portrayed as a study to funders. The present project that provided HCV-related services was portrayed that way; the mental health component already had dedicated funding.
The services provided by the nurse-run HCV health project included the following:
- testing for blood-borne viruses such as hepatitis B virus (HBV), HCV and HIV
- HCV treatment
- specialized ultrasound scans of the liver to determine the degree of HCV-related injury
- peer mentors
- social and psychiatric support
- provision of new needles and syringes
- opioid substitution therapy
People who tested positive for HCV antibodies were recalled and offered HCV RNA testing, which determines whether the infection is active.
Other tests, such as gastroscopy, were offered as needed.
People with infections such as HBV or HIV were referred to other centres for care.
The project nurse was trained in providing care for people with HCV and people with mental health issues.
A hepatologist visited the project centre once a month to give advice to the nurse about the care needed by people with complex liver disease.
HCV treatment
All people who tested positive for HCV RNA were considered eligible for HCV treatment, whether or not they had ongoing drug and/or alcohol-related issues.
The project nurse presented information about each patient eligible for HCV treatment to a regional multidisciplinary team so that consensus could be reached on a decision to offer such treatment.
After a decision was made to offer HCV treatment, another nurse delivered the treatment at the project centre. Patients were supervised when taking DAAs either by the centre’s staff or via phone calls, depending on the situation.
Care engagement strategies
Over the course of the study, researchers found that people who sought care had increasingly complex needs. To help increase access to care, the centre did the following in response to the rising complexity of patient needs:
- the project nurse trained staff who dealt with substance use issues, so that every visit to the centre became an opportunity for viral testing (if needed)
- increased the use of peer mentors and social workers who could accompany patients to appointments and help dispel any misinformation and stigma about DAA treatment
- offered vouchers for food to encourage testing for blood-borne viruses, initiation of HCV treatment and attending appointments
As some patients did not want to attend the centre, nurses sometimes delivered an entire course of treatment at the patient’s home or a homeless shelter. At the shelter, lockers were provided to store DAAs. If necessary, shelter managers and peer mentors could supervise patients when they took a dose of medicine.
Study details
Nurses collected health-related information from 765 participants between 2013 and 2021. This data was subsequently analysed and formed the basis of a sub-study on the effectiveness of HCV treatment.
The average profile of participants upon entering the study was as follows:
- age – 18 to 40 years old
- 78% male, 22% female
- 34% currently injected drugs and 40% inhaled or swallowed drugs
- 55% were experiencing homelessness
- nearly 60% had been diagnosed with a mental health condition
- 58% were taking opioid substitution therapy
- 41% had experienced drug poisoning
- 98% had shared equipment for using drugs
- 20% had ultrasound results suggestive of extensive scarring of the liver (cirrhosis)
Of the 765 participants, 413 tested positive for the genetic material (RNA) of HCV, indicating that they had active infection. Of these people, 405 were eligible for treatment and 67% of these (272 people) received treatment.
The most common reasons that people who were eligible for treatment did not receive it were as follows:
- chose to be treated at another centre – 43%
- died before treatment could be initiated – 25%
- moved or stopped using the centre – 19%
Treatment success
Overall, 96% of participants who initiated HCV treatment and who maintained visits to provide blood samples at the end of treatment were cured. Rates of cure were greater (97%) toward the end of the study. This increase in cure occurred despite more patients having more competing priorities than those who sought care at the beginning of the study in 2013.
Not cured
Among 39 people who initiated HCV treatment but were not cured, only 10 developed HCV that was partially or wholly resistant to treatment. The remaining participants were not cured because they did not take sufficient doses of DAAs.
Among the 39 people who were not cured, 11 were re-treated and 10 were subsequently cured.
Reinfection
Among people who were cured, 146 were subsequently retested for HCV. Eleven people were reinfected. Nine of the 11 people were either partners with each other or lived together in homeless shelters. All people who were reinfected were eligible for retreatment.
Deaths
During the study, 86 out of 745 participants (about 12%) on whom data were available died. Researchers were able to identify causes of death for some of these people. The common causes of death were as follows:
- drug poisoning – 39 people
- liver-related complications – 8 people
The researchers stated that the isolation caused by the global COVID-19 pandemic might be one factor that contributed to the deaths of participants.
Bear in mind
Despite multiple issues, including the COVID-19 pandemic, a decentralized service that provided integrated care in one place was able to achieve high rates of screening for viral infections and HCV cure. The model of care delivered by the project has been internationally recognized for its work with patients and success at curing HCV.
If progress is to be made toward ending HCV as a public health threat by 2030, more people at risk for HCV need low-barrier access to HCV testing and treatment. They also need help with pre-existing conditions, keeping appointments and navigating healthcare-related services.
Beyond HCV cure
Note that 86 people died during the study. These deaths underscore the necessity to provide an array of services that can meet the needs of people with complex lives and competing priorities so that deaths can be prevented. Data from the UK Office of National Statistics indicate that the number of people who have died from drug poisoning in England and Wales has increased over the past decade. A similar trend is happening in Canada and the U.S. This crisis needs comprehensive attention and investment if the life expectancy of people with HCV and those at risk for HCV is to be improved.
—Sean R. Hosein
Resources
Deaths related to drug poisoning in England and Wales: 2022 registrations – Office of National Statistics (UK)
Co-located hepatitis C testing and care at a supervised consumption service – Programming Connection
Hepatitis C basics – CATIE
Hepatitis C testing and diagnosis – CATIE
Hepatitis C medications – CATIE
Blueprint to inform hepatitis C elimination efforts in Canada — Canadian Network on Hepatitis C
Harm Reduction Fundamentals: A toolkit for service providers — CATIE
Large study explores alcohol use and hepatitis C treatment – CATIE News
Canadian study finds hepatitis C cure leads to gradual improvement in symptoms of depression in people with HIV – CATIE News
U.S. study finds less access to important surgeries in people with HIV or hepatitis C virus and in racialized groups – CATIE News
Alberta researchers find high rates of hepatitis C virus and syphilis co-infection during pregnancy – CATIE News
Researchers underscore the need for high-tech tests to uncover acute hepatitis C virus infection – CATIE News
REFERENCE:
O’Sullivan M, Jones AM, Mourad A, et al. Excellent hepatitis C virus cure rates despite increasing complexity of people who use drugs: Integrated-Test-stage Treat study final outcomes. Journal of Viral Hepatitis. 2024 Feb;31(2):66-77.