Medical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection

Abstract

Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy.

Keywords: HCV; HCV treatment; persons with substance use disorders.

FIGURE 1

Venues providing access to different populations of persons with substance use disorders. Efforts to provide care to populations of persons with substance use disorders may frequently require expansion beyond the conventional health care setting. The ability to access persons with substance use disorders directly at venues where they habitually congregate or receive treatment could be a means to overcome the stigmatization associated with hepatitis C virus infection and the reluctance to seek care within a conventional health care setting. These alternative sites vary greatly in terms of accessibility and degree of health care services administered and in many cases may require outreach or integration of the hepatitis C virus provider into the particular setting.

FIGURE 2

Models of care in telehealth (A) and conventional settings (B). A, In a telehealth model, the patient and the health care provider are each geographically separated and connected using technology, such as through the use of text messages, telephones, or telemedicine (ie, 2-way videoconferencing between a patient and a physician each located remotely). Technology can also be used to transmit data from a physician to a patient, vice versa, or between physicians. For example, a patient portal enables patients to view their test results, remote patient monitoring permits results (ie, glucose or blood oxygenation) to be transmitted from a patient to a physician, and digital images can be transmitted for remote review by a radiologist. B, In conventional health care settings, persons with substance use disorders are typically referred to a health care provider to obtain treatment for hepatitis C virus infection. Alternatively, a health care provider could engage directly with persons with substance use disorders through an integrated care model in which hepatitis C virus care is delivered directly in the venue that offers treatment for substance use. Case management, patient education, peer navigation, and patient navigation are important interventions that can support persons with substance use disorders access to care and adherence.