Hepatitis C Care Cascade In IV Drug Users: Scientific Journal of Gastroenterology and Hepatology (SJGH)- ISSN : 2641-5585

Hepatitis C Care Cascade In IV Drug Users

ONOMY Science

 Scientific Journal of Gastroenterology and Hepatology (SJGH)- ISSN: 2641-5585

        Many people who are infected with the hepatitis C virus (HCV) remain undiagnosed and untreated. Although those born between 1946 and 1964 represent most of the population with chronic  HCV infection,  persons who inject drugs (PWID) now make up the largest population of new cases of the disease. Up to 90% of all new HCV infections worldwide and at least 75% of those in the United States are attributed to the use of injected drugs.

         An estimated 10 million PWID are infected with HCV worldwide, creating a significant infectious reservoir for the continued spread of this virus. Control of HCV infection among PWID will require targeted strategies to address the “HCV cascade of care”—enhancing diagnosis, linking individuals to HCV care, increasing treatment uptake, and enhancing viral cure.

New Drug Users at Risk

Individuals who are newly initiated into IV drug use, namely young PWID (age, 17-5 years), are most at risk. Often, prescription opioid abuse at an early age leads to the use of injected drugs and heroin, which, in turn, is associated with increasing HCV infection among young people.²

An estimated 45% of young PWID in the United States are infected with HCV, and the annual incidence is 8% to 25%. From 2006 to 2012 in nonurban areas of the United States, the incidence of acute HCV infection increased significantly among young people: a 1% annual increase, correlating with a 170% increase over 6 years. Young, suburban heroin users are described as the “second wave of HCV infection” in several US states.

Young adults are at increased risk because they often inject in a social environment, pooling money to purchase drugs and then sharing both needles and drug preparation equipment for injection. HCV is viable for days in dried blood and for weeks in syringes.⁷ Transmission of HCV via drug paraphernalia is 5 times higher than the transmission of HIV due to this extended viability. Thus, it is not surprising that young PWID is a very high-risk population for contracting HCV.

Novel Patient Care Models

Targeting PWID is an effective way to eliminate HCV infection in the community. To fully achieve this goal, novel patient care models are needed to facilitate the flow of HCV-positive patients from institutions to medical care after diagnosis. A plan to capture this at-risk population for HCV treatment involves increasing education, screening, and linkage to available care by working with facilities such as opioid substitution therapy clinics/medication-assisted treatment centers, sober living homes, drug rehabilitation centers, federally qualified health centers, and city/county health departments.

Challenges in the HCV Care Cascade

There are multiple challenges in this HCV care cascade. One challenge in testing PWID, particularly in community settings, is screening and linkage to care about a positive HCV test. Akyar et al showed HCV screening was easily attainable in an active opioid detoxification program in Princeton, New Jersey, although linking patients to care was more difficult. Even with encouragement, only 16 patients (8.6%) returned for in-office follow-up visits, and only 2 started treatment. Follow-up, after patients left the program, was a logistical problem because of patient relocation, limited availability of transportation, and communication issues between patients and health professionals.

Linkage to Care Strategies

Integrating Testing With Other Health Care Services

Successful strategies for enhanced linkage to HCV care for PWID include the integration of HCV testing and care into existing health care services for PWID, such as drug and alcohol abuse rehabilitation, primary care, and prison-based settings. In a randomized controlled trial examining the efficacy of a model of hepatitis care coordination (including motivational interviewing, enhanced patient navigation, and case management services) in the opioid substitution therapy setting, participants receiving the intervention were 4 times more likely to undergo assessment for HCV infection. In a study by Fortier et al evaluating HCV assessment and treatment among PWID attending opioid therapy clinics, poor social functioning was common among PWID and was associated with reduced intent to receive early HCV treatment and specialist assessment, indicating that enhanced support before treatment may be important for improving linkage to HCV care.

Use of Care Coordinators

Studies have demonstrated that disadvantaged subgroups of PWID are less likely to seek health care because of fear of stigma, discrimination, judgmental attitudes, and misunderstanding of their needs and their lifestyle by health care providers. Treloar et al found that a trusted HCV peer support worker, nurse, or specialist may help eliminate patient barriers to HCV care related to social functioning that might be present when the patient is considering treatment or before engagement with an HCV specialist.  Linkage-to-care rates also were higher in the Treloar study than rates observed in Philadelphia surveillance data, likely because of the creation of the linkage-to-care coordinator position.

Initially, linkage services included reminder phone calls, public transportation tokens for patients to attend appointments, and patient escorts. However, some patients required additional services. The linkage-to-care coordinator provided intensive support services: following up with patients who did not keep appointments; conducting off-site visits (eg, home, shelters, and halfway houses) as necessary; acting as an intermediary point of contact between the patient and the federally qualified health centers; and helping identify and resolve any barriers patients experienced in attending appointments (Table). These services fostered trusting relationships with patients.

Additionally, the care coordinator remained a point of contact for HCV-infected patients who had fallen out of care because of addiction, unstable housing, or distrust of health care systems. Care coordinators also worked with patients until they were ready to reengage in care, linked them to social and addiction support programs, and provide specialized care plans to ensure they attended their HCV medical appointments. Similar intensive linkage services in community-based HCV testing and linkage-to-care programs in Philadelphia also have proven successful in navigating HCV-infected patients into care.

Online Health Tools

Electronic health engagement could emerge as a tool for linking PWID patients to the HCV care cascade. Linkage to Care (LTC) (www.linkagetocare.com) is a strict HIPAA-compliant online patient database management system (PDMS). The online PDMS is an access point for linking individuals to care, and the data are held in a secure HIPAA-compliant server that is exclusive to this project. Individuals whose data are entered into the PDMS are tracked to determine the referral option selected, medical notes, and pertinent information related to appointments. Using this program, Tariq et al showed that 1,141 PWID patients were screened at 16 drug rehabilitation facilities; 27% were HCV antibody–positive and 197 were HCV RNA–positive (Figure). Of the 197 HCV-infected PWID patients, 148 (75%) initiated an LTC protocol starting with education, 85 (90%) had appointments to see a medical provider scheduled by an LTC navigator/specialist, and 22 (26%) attended their first medical appointment.

Virtual Integration of Care by Telemedicine

The conventional method of HCV treatment delivery—referral to an off-site location—has discouraged many PWID from initiating or completing treatment. These individuals may have low literacy, transportation difficulties, and multiple medical conditions, including depression and anxiety, that hinder them in seeking treatment for HCV.

To overcome these issues, advocates have supported integration of treatment for substance abuse and HCV infection, but physical integration has been difficult to achieve because such services often are not available in the same clinic. Telemedicine using 2-way live video conferencing between a physician and a patient in separate geographic locations permits virtual integration and has been used as a treatment delivery strategy for PWID. Preliminary results with 18 patients in New York City, who received biweekly telemedicine conferences with Andrew H. Talal, MD, MPH, from the University at Buffalo, in New York, has been promising.

Conclusion

This is an exciting era for the field of HCV. Strategies to manage HCV infection among PWID will need to be integrated into existing foundations for prevention and health care for PWID, in partnership with the affected community and with a commitment to tackling stigma and discrimination associated with injection drug use and HCV.20 Control of HCV infection among PWID will require targeted strategies to enhance HCV diagnosis, link individuals to HCV care, increase treatment uptake, and enhance viral cure, collectively termed the “HCV cascade of care.” A major challenge will be to develop and implement programs appropriate for different settings.