To Engage Injection Drug Users in HCV Care, Go to Where They Are

For injection drug users with hepatitis C virus (HCV) infection, providing treatment opportunities within a local needle exchange program can provide care to more patients and eventually cure more patients, a new study suggests.

The study's findings help "counteract the implicit belief within the medical community that people who inject drugs can't or don't want to engage in healthcare," lead author Benjamin Eckhardt, MD, with NYU Grossman School of Medicine in New York City, told Medscape Medical News.

"By simply focusing on patient accompaniment, limiting stigma, and removing the punitive response for missed appointments, we can effectively engage people who inject drugs in healthcare and more specifically cure their infection, making significant inroads to HCV elimination," Eckhardt said.

The study was published online March 14 in JAMA Internal Medicine.

Nonjudgmental, Patient-Centered Approach

Researchers included 165 injection drug users with HCV (mean age, 42 years; 78% men); 82 were randomly allocated to the accessible care intervention, and 83 to a usual care control group.

The accessible care model provides HCV treatment within a community-based needle exchange program in a comfortable, nonjudgmental atmosphere, "without fear of shame or stigma that people who inject drugs often experience in mainstream institutions," the investigators explain.

Control participants were connected to a patient navigator who facilitated referrals to community direct antigen antiviral therapy programs that were not at a syringe service program.

In an intent-to-treat analysis, those enrolled in the accessible care group achieved sustained viral eradication at 12 months at significantly higher rates than those in the control group (67% vs 23%; P < .001).

Once patients initiated treatment, cure rates were the same in both groups (86%), indicating that the major benefit of the accessible care program was in facilitating treatment, rather than increasing adherence or response to treatment, the researchers noted.

This is reflected in the fact that the percentage of participants who advanced along the care cascade was significantly higher at each step for the accessible care group than the control group, from referral to an HCV clinician (93% vs 45%), attendance of the initial HCV clinical visit (87% vs 37%), completion of baseline laboratory testing (87% vs 31%), and treatment initiation (78% vs 27%).

Getting to the Population in Need

"The most surprising aspect of the study was how successful we were at recruiting, engaging, and treating people who inject drugs who lived outside the immediate community where the syringe exchange program was located and had no prior connection to the program," Eckhardt told Medscape Medical News.

"We had numerous individuals travel 45-plus minutes on the subway from the South Bronx, passing four major medical centers with robust hepatitis C treatment programs, to seek care for hepatitis C in a small, dark office ― but also an office they'd heard can be trusted ― without fear of stigma or preconditions," Eckhardt said.

Commenting on the study's findings for Medscape Medical News, Nancy Reau, MD, section chief of hepatology at Rush Medical College in Chicago, Illinois, said, "This is another successful example of making therapy accessible to the population who is in need vs trying to move them into a tertiary care model."

Reau noted that similar care models exist in the United States but are not always accessible to the population in need.

"The safety and efficacy of current therapy and the simplified care cascade make HCV an appropriate disease for this delivery," she said, adding that this study "highlights not just the importance of these programs but also the necessity of engaging the medical community, changing policy, and using patient navigators and monetary support/prioritization to provide appropriate HCV management to those who are at high risk for the disease and for transmission."

Accessible Care Beyond HCV

The co-authors of an accompanying editor's note point out that the treatment for HCV has improved substantially, but it can be a real challenge to provide treatment to injection drug users because the US healthcare system is not oriented toward the needs of this population.

"It is not surprising that the accessible care arm achieved a higher rate of viral eradication, as it created a patient-focused experience," write Asha Choudhury, MD, MPH, with the University of California, San Francisco, and Mitchell Katz, MD, with NYC Health and Hospitals. "Creating inviting and engaging environments is particularly important when caring for patients from stigmatized groups. Having more sites that are accessible and inclusive like this for treating patients will likely increase treatment of hepatitis C."

In their view, the study raises "two dueling questions: Is this model replicable across the US? And, conversely, why isn't all medical care offered in friendly, nonjudgmental settings with the intention of meeting patient goals?"

They conclude that the study's lessons extend beyond this particular population and have implications for the field at large.

"The model is replicable to the extent that health care systems are prepared to provide nonjudgmental supportive care for persons who inject drugs," they write. "However, all patients would benefit from a health care system that provided more patient-centered environments."

The study was funded by the National Institute on Drug Abuse. Eckhardt reports receiving grants from the National Institutes of Health and Gilead during the conduct of the study. Choudhury, Katz, and Reau report no relevant financial relationships.

JAMA Intern Med. Published online March 14, 2022. Abstract, Editorial

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