The peer-assisted telemedicine hepatitis C treatment (TeleHCV) program combines peer support with telemedicine to enhance hepatitis C treatment. A randomized controlled trial conducted in seven rural Oregon counties found that participants in the TeleHCV program were significantly more likely to initiate treatment and achieve a cure than those who received peer-assisted referral to local providers (the control arm). Specifically, 85% of TeleHCV participants enrolled in treatment and 66% achieved a cure, compared with 12% and 16%, respectively, in the control arm.1
Program description1,2
The TeleHCV program aimed to reach people who use drugs in rural and remote areas by implementing peer-assisted telemedicine treatment for people with hepatitis C. People who use drugs (defined as reporting injecting drugs or using nonprescribed opioids within the past 90 days) were recruited by peers in seven rural Oregon counties with high rates of hepatitis C and opioid overdose. Participants were recruited at needle and syringe programs and outreach sites (e.g., parks, encampments, shelters) and through participant referrals.
The program used peers, known as peer support specialists (PSS), who brought lived or living experiences of substance use and helped participants to navigate health systems, as well as address and reduce stigma. PSS performed eligibility prescreening and rapid hepatitis C antibody testing unless participants self-reported that they had hepatitis C. For all participants who had a reactive hepatitis C antibody test or who self-reported hepatitis C, peers:
- facilitated pretreatment evaluations at local laboratories, including providing transportation
- advocated for participants while navigating health systems
- supported people in managing challenges with blood tests, particularly for people with a history of injection drug use
- shared laboratory results with participants
Participants with detectable RNA were randomly assigned to the TeleHCV or control arm of the study. In the control arm, participants received enhanced usual care (EUC): peers referred them to local services, including facilitating connections to other local peer workers, providing a list of local hepatitis C screening and treatment providers and offering direct referrals to staff at local healthcare organizations.
As soon as possible following their random assignment to a study arm, TeleHCV participants were scheduled for an initial telemedicine visit and hepatitis C assessment by a study clinician (e.g., physician, nurse practitioner, clinical pharmacist), with the goal of facilitating same-day appointments and in some cases same-day treatment initiation.
In the TeleHCV arm, peers supported participants in navigating through screening and treatment including:
- helping participants complete insurance enrolment forms
- facilitating telemedicine visits (e.g., by bringing telecommunication devices)
- reaching out to participants in precarious housing situations (e.g., parks, encampments, shelters)
- delivering medications and assisting with secure medication storage at syringe service programs
- supporting medication adherence through follow-ups
- offering harm reduction supplies
- linking participants to substance use treatment (if requested by the participant)
- facilitating follow-up laboratory testing 12 weeks after the end of treatment
The TeleHCV clinical team included two internal medicine physicians, a physician assistant, a clinical pharmacist and a team of trained peers. The TeleHCV clinical team provided same-day unscheduled appointments, communicating directly with peers to discuss participant concerns and conducting four-week medication adherence follow-up calls. Peers carried a tablet with Internet connectivity to facilitate telemedicine visits for participants if they did not have their own access. If additional tests were necessary for clinical decision-making, peers assisted participants in navigating health system barriers and arranged follow-up telemedicine appointments with the TeleHCV treatment provider.
Medications were mailed to a home address or a local partner organization (e.g., needle and syringe programs) for participants. The clinical pharmacist contacted participants via telephone or telemedicine at week zero and week four to confirm that the participants had received their medications and to determine medication tolerance and assess adherence.
Results1
This study compared hepatitis C cure rates among those participating in the TeleHCV arm of the study and those participating in the EUC arm of the study. Between July 2020 and December 2022, 774 individuals were screened for participation. Of these individuals, 227 had detectable RNA, 221 were eligible and 203 participants were randomly assigned to a study arm. There were 100 participants in the TeleHCV arm and 103 in the EUC arm.
Across both groups:
- the average age of participants was 42 years
- 62% of participants identified as male and 38% as female
- 88% of participants identified as White, 7% as Native American, 2% as multiracial, 1% as Black and 2% identified in another way
- 70% of participants reported experiencing homelessness in the previous six months
- in the past 30 days, 62% reported using nonprescribed unregulated opioids (52% heroin, 33% fentanyl) and 88% reported using methamphetamine at least once
Participants in the TeleHCV arm were nearly seven times more likely to initiate treatment than those in the EUC arm (85% [85/100] in the TeleHCV arm versus 13% [13/103] in the EUC arm, a statistically significant difference). Those in the TeleHCV arm were five times more likely to complete treatment, with 46% (46/100) completing treatment compared with 9% (9/103) in the EUC arm (a statistically significant difference). Among those who initiated treatment, treatment completion rates were similar (54% in the TeleHCV arm versus 69% in the EUC arm).
Participants assigned to the TeleHCV arm were four times more likely to achieve hepatitis C cure 12 weeks after treatment completion, with 63% (63/100) achieving a cure compared with 16% (16/103) in the EUC arm. Among those who initiated treatment, cure rates were similar at 12 weeks after treatment, with 74% (63/85) cured in the TeleHCV arm and 77% (10/13) cured in the EUC arm. The most common reasons for not achieving viral clearance reported by 37 TeleHCV participants included treatment noncompletion or reinfection (59%), noncompletion of laboratory testing (27%) and non-initiation of direct-acting antiviral medications (14%). Of note, among those who did not complete treatment but were cured (27), 93% reported that they were 80% adherent at their first follow-up. The study was unable to distinguish between treatment failure and reinfection when cure rates were measured 12 weeks after treatment completion.
What does this mean for service providers?1
The results of this study highlight the critical importance of engaging people with lived and living experience of substance use as peers in implementing interventions affecting people who use drugs and suggest that service providers should consider peer-assisted telemedicine models in hepatitis C treatment programs. The use of low-barrier, peer-assisted telemedicine helped overcome barriers associated with decreased treatment initiation among people who use drugs living in rural areas.
As a scalable model that is applicable to most rural areas, peer-assisted TeleHCV programs are promising interventions for screening and treating people who use drugs living with hepatitis C. This model offers a powerful new tool for rural communities working toward eliminating hepatitis C.
Related resources
CATIE statement on hepatitis C treatment efficacy among people who use drugs – CATIE statement
Harnessing community paramedics to treat hepatitis C in rural and remote regions – CATIE Programming Connection evidence brief
Hepatitis C reinfection: Risks, realities and responses – CATIE Prevention in Focus article
Hepatitis C treatment in harm reduction programs for people who use drugs – CATIE Prevention in Focus article
References
- Seaman A, Cook R, Leightling G et al. Peer-assisted telemedicine for hepatitis C in people who use drugs: A randomized controlled trial. Clinical Infectious Diseases. 2024, ciae520. https://doi.org/10.1093/cid/ciae520
- Herink M.C, Seaman A, Leichtling G et al. A randomized controlled trial for a peer-facilitated telemedicine hepatitis C treatment intervention for people who use drugs in rural communities: study protocol for the “peer tele-HCV” study. Addiction Science & Clinical Practice. 2023;18:35. https://doi.org/10.1186/s13722-023-00384-z