A greater uptake in hepatitis C virus (HCV) treatment for people who inject drugs (PWID) at a community center led to decreases in liver disease and mortality, a longitudinal cohort study found.
Among 1,323 PWID with chronic HCV at a Baltimore community-based center, the number of those with HCV RNA declined from 100% in 2006 to 48% in 2019, while self-reported treatment grew from 3% in 2014 to 39% in 2019, reported David L. Thomas, MD, of the Johns Hopkins School of Medicine in Baltimore, and colleagues.
And those with undetectable HCV RNA were 72% less likely to develop cirrhosis (adjusted odds ratio 0.28, 95% CI 0.17-0.45) and had a 46% lower risk for all-cause mortality (inverse probability treatment weighting [IPTW] adjusted HR 0.54, CI 0.38-0.77), they wrote in Annals of Internal Medicine.
Among 10,350 valid liver stiffness measures (LSMs), cirrhosis was identified in 15% in 2006 and 19% in 2015, but dropped to 8% in 2019.
“Despite all the socioeconomic and structural challenges, some persons who inject drugs are receiving treatments for HCV infection and those treatments are reversing the worrisome trend of a rising incidence of liver cirrhosis,” Thomas told MedPage Today.
“However, we also found that some persons still remain untreated, even 5 years after the medications became widely available,” Thomas said.
“For more than a decade prior, uptake of interferon-based HCV treatment was <5%,” said co-author Shruti Mehta, PhD, also of Johns Hopkins. “Even though we expected an increase in uptake with the advent of direct acting antivirals, I think the rate of uptake was even higher than expected.”
Although the World Health Organization and the U.S share a goal of achieving HCV elimination by 2030, a low uptake of treatment remains among PWID, Thomas’ group noted. Over 95% of those treated for HCV can be cured. In order to achieve an elimination target of a 65% reduction in HCV-related mortality, not only identification, but linkage to care, and cure for those infected should occur, “because cure is conditional on access to care,” they wrote.
“Because they are disproportionately uninsured or covered under Medicaid, restrictions on HCV treatment reimbursement based on liver disease severity have limited HCV treatment opportunities for PWID in many states” the researchers noted. PWID also have more comorbidities — alcohol use disorder (AUD) or HIV — that impact HCV treatment benefits.
“We did the study because nearly all HCV infections in the United States are related to injection drug use and some really effective medical treatments might not ever be received by persons who inject drugs because of multiple personal and structural challenges,” Thomas explained.
Reached for comment, Anthony Martinez, MD, of the University at Buffalo in New York, said the findings point to progress in treating HCV among PWID, given that over 50% of the cohort had received treatment.
“While a significant number of patients remain chronically infected, this level of treatment uptake is much higher than what we have seen in the past, where the rates have been less than 20%,” said Martinez, who was not involved in this study. “It’s clear from this study that while we have a lot of work to do, we are making progress in terms of elimination efforts.”
Thomas and colleagues examined data on 1,321 PWID with chronic HCV who were enrolled in the ALIVE study from 1988 through 2019. Adults residing in or near Baltimore, who visited a community-based clinic biannually and underwent interviews, were included. Participants had to have HCV DNA detected and a valid LSM assessed by transient elastography using FibroScan. Median follow-up was 5 years per person. Each participant had an average of six LSMs. IPTW analysis adjusted for demographics, AUDs identification test (AUDIT) category, BMI, HIV status, among others.
Median age was 49 and 71% were men. Most participants were Black individuals (82%). About half were underweight or had a normal BMI. The majority had no comorbidities (47%) or only had one comorbidity (42%). Two-thirds did not have HIV. Within the last 6 months, over half injected drugs (54%) and 27% were on methadone. Only 15% had cirrhosis, evidenced by a LSM≥12.3 kPa. One-third had severe alcohol use, while 23% had harmful or hazardous alcohol use, based on AUDIT scores.
During 2006 to 2019, 430 participants died — 394 who still had chronic HCV and 36 with undetectable HCV RNA. Of those, 29% were from drugs/trauma, 41% from chronic disease, and 6% from liver disease/cirrhosis.
Study limitations included the fact that noninvasive markers for liver fibrosis were not validated in individuals who have sustained virologic response. Also, findings might only be generalizable to the Baltimore area.
Disclosures
The study was supported by the NIH, the National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Heart, Lung, and Blood Institute, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute on Drug Abuse (NIDA), National Institute of Diabetes and Digestive and Kidney Diseases, National Institute on Aging, National Institute of General Medical Sciences, National Institute on Minority Health and Health Disparities, and the Johns Hopkins University Center for AIDS Research.
Thomas disclosed relationships with the NIH, Merck DSMB, Excision Bio, Johns Hopkins University, CME programs, and UpToDate. Metha disclosed support from, and/or relationships with, the NIH, Patient-Centered Outcomes Research Institute, United States Agency for International Development, and Gilead Sciences.
Co-authors disclosed relationships with the Abbott Diagnostics, NIH, NIDA, UW‐Madison Institute for Clinical and Translational Research, and the UW‐Madison Wisconsin Partnership Program.
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