Hepatitis C Treatment Outcomes Among Patients Treated in Co-located Primary Care and Addiction Treatment Settings
By Dr. Mark Gold
The incidence of hepatitis C (HCV) has increased sharply since 2010, owing to the opioid epidemic and injection drug use among adults under age 30.1 The advent of direct-acting antivirals (DAAs) has made treatment of chronic HCV infection straightforward, and has transformed how and where treatment can be administered as well as patients' treatment-related experiences and outcomes.2 Although the vast majority of persons who are diagnosed with HCV can be treated, populations with the highest prevalence (diagnosed and undiagnosed), transmission, and reinfection rates—such as people with substance use disorders (SUDs)—have limited access to health systems and services.1
Given the availability of DAAs and HCV screening tools, the World Health Organization in its quest to eradicate HCV, set global elimination targets for this infection: treatment of 80% of those eligible, reduction by 90% in the incidence of new infections, and reduction by 65% in liver-related mortality.3 However, achieving these goals has proven to be challenging. Efforts must focus on marginalized populations, including but not limited to people with SUDs, due to the high prevalence of infection, risk behaviors, and poor linkage to care in this population. In this regard, incorporation of HCV treatment into clinics (colocation) providing care for individuals with SUD is an important elimination strategy.2 The body of evidence supporting this approach is accumulating.4-7 The study by Ngo et al is highlighted.
Ngo et al evaluated outcomes of HCV treatment in an observational study of 50 patients treated with DAAs by primary care providers (PCPs) in two sites with co-located addiction and HCV care services: a hospital-based primary care clinic with an embedded office-based buprenorphine program and a primary care clinic within an opioid treatment program. The primary outcome was sustained virologic response at 12 weeks (SVR12).8 Demographic and clinical factors, including those that were demonstrated in prior studies to influence treatment adherence and SVR12, were also evaluated.
SVR12 was achieved in 94.4% of participants, which is consistent with results of other real-world studies.8 There were no documented cases of reinfection among the 44 patients who achieved SVR12 during the study period.8 These results are notable considering that 74% of patients in the study were unemployed, 80% had psychiatric comorbidities, 22% experienced homelessness during treatment, and 36% had been previously incarcerated.8
Why is this important?
The prevalence of HCV is substantially higher among patients with SUDs than in the general population. Physicians caring for patients with SUDs should evaluate them for HCV and refer those with positive results for treatment.9 This study adds to the body of research demonstrating that high SVR12 rates can be achieved among patients with SUDs within primary care settings that are co-located with addiction treatment services. The real-world results of this study support the feasibility and effectiveness of programs that co-locate HCV and addiction treatment, and highlight the role of PCPs to treat and cure HCV among patients with and without SUDs.
This is feasible because treatment of HCV is straightforward with the availability of safe and effective therapies. Indeed, the investigators in this study used the American Association for the Study of Liver Diseases / Infectious Diseases Society of America (AASLD/IDSA) HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis.10 Of note, the most recent update of the AALSD/IDSA HCV management guidance provides a one-page tool for the use of the simplified HCV treatment algorithm.11
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Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food.
1. Centers for Disease Control and Prevention [CDC]. Surveillance for viral hepatitis – United States, 2017. CDC Website. https://www.cdc.gov/hepatitis/statistics/2017surveillance/index.htm. Last reviewed November 14, 2019. Accessed June 19, 2021.
2. Alshuwaykh O, Kwo P. Current and future strategies for the treatment of chronic hepatitis C. Clin Mol Hepatol. 2021;27:246-256.
3. World Health Organization [WHO]. Global health sector strategy on viral hepatitis 2016-2021. WHO Website. https:
//apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf;jsessionid=60A93ADD1A191FF6A0FA823314D24C43?sequence=1 (WHO, 2016). Published June 2016. Accessed June 19, 2021.
4. Rosenthal ES, Silk R, Mathur P, Gross C, Eyasu R, Nussdorf L, et al. Concurrent initiation of hepatitis C and opioid use disorder treatment in people who inject drugs. Clin Infect Dis. 2020;71:1715-1722.
5. Palmateer NE, McAuley A, Dillon JF, et al. Reduction in the population prevalence of hepatitis C virus viraemia among people who inject drugs associated with scale-up of direct-