Implementing a new HCV model of care for people who use drugs

Abstract

Background & aims: An estimated 50 million individuals have chronic hepatitis C virus (HCV) infection worldwide and people who use drugs (PWUD) are disproportionately affected. Persistent stigma and discrimination make it challenging for PWUD to access healthcare, potentially hindering HCV elimination progress in this population. To mitigate healthcare access barriers in PWUD, an HCV care model that simplified screening and linkage to care pathways was developed and rolled out in the Balearic Islands, Spain.

Methods: The prospective multicentre community model of care was implemented in 21 centres serving PWUD. This model involved: (1) participant recruitment and HCV antibody screening onsite via a point-of-care anti-HCV test, phlebotomy, or laboratory records; (2) HCV RNA, HBsAg and anti-HIV testing via a dried blood spot or phlebotomy; (3) linkage to specialist care and treatment prescription via telemedicine, when required; and (4) onsite monitoring of: (a) sustained virologic response (SVR) 4 and ≥12 weeks after treatment completion and; (b) potential new HCV infection or reinfection ∼1 year after phase 1 or SVR ≥12 monitoring. Care model acceptability was assessed.

Results: Between April 2021 and April 2023, 1,423 participants were recruited, of whom 464 (33%) were anti-HCV+ and 170 (12%) had detectable HCV RNA. Of the latter, 147 (86%) initiated therapy, of whom 124 (84%) completed it. SVR ≥12 monitoring was performed in 95 (77%) of these, of whom 88 (93%) had undetectable HCV RNA. Upon re-screening, four HCV reinfections were detected. Over 90% accepted study participation and screening and treatment decentralisation.

Conclusions: This adapted care model, which decentralised screening, diagnosis, and treatment, effectively increased healthcare access among PWUD, improving progress towards HCV elimination in this population in Spain.

Impact and implications: People who use drugs (PWUD) are among the most affected by chronic hepatitis C virus (HCV) infection globally. A simplified model of care was implemented in 21 centres serving this population across the Balearic Islands, Spain, to offer HCV care to 1,423 PWUD in 2021-2023. This decentralised screening, diagnosis, and treatment model resulted in an HCV cure rate of 93% of those who both completed therapy and were monitored post treatment completion. The Hepatitis C Free Balears model can guide the HCV elimination efforts of regional health authorities and other stakeholders in the rest of Spain and other parts of the world.

Keywords: Balearic Islands; Hepatitis C virus; Marginalised population; Micro-elimination; Point-of-care testing; Spain; Telemedicine; Viral hepatitis.

Graphical abstract

Fig. 1

Study phases. DBS, dried blood spot; DTCA, delegated treatment collection authorisation; PWUD, people who use drugs; SVR, sustained virologic response.

Fig. 2

Study sites. Map of the Balearic Islands (left to right: Ibiza, Formentera, Mallorca, and Menorca) with the location of the participating study centres. NGO, non-governmental organisation; UCA, Unitat de Conductes Addictives (addictive behaviour units).

Fig. 3

Cascade of care flow-chart. ∗Only participants who were screened up until April 2022 (n = 821) were eligible for being screened again, as the study closed in April 2023 and there had to be ∼1 year between the first and second screening session. SVR12, sustained virologic response 12 weeks after treatment completion.

Fig. 4

Cascade of care overall and by setting. Percentages were calculated in relation to the total number of participants (n = 1,423). For the overall chart n = 1,423, addictive behaviour units chart n = 936, NGO centres chart n = 384, social inclusion centres chart n = 90, and mobile methadone bus chart n = 13. Percentages in yellow on the ‘anti-HCV tested’ bar represent those participants with a confirmed past HCV infection after confirmation. NGO, non-governmental organisation.

Fig. 5

Model of care acceptability. (A) Study participation acceptance; (B) HCV screening preference; (C) HCV treatment preference in Mallorca.