Q & A: Treating People Who Inject Drugs

Issue: June 2016

Injection drug users have long comprised the largest and, in many ways, most challenging population in the field of hepatitis C. They have historically been difficult to bring into care and prone to high-risk behaviors that lead to reinfection.

Competing physical and mental health care priorities are increased in people who inject drugs (PWID), which has makes it necessary to be careful about the tenor and nature of talking points throughout the continuum of care. For understandable reasons, adherence in the interferon era was inconsistent, and data are still emerging as to whether PWID are more adherent to direct-acting antiviral therapies. But now that those therapies are becoming more accessible, HCV Next tackled these issues head-on in a question-and-answer format with a host of experts in the clinical and research fields.

The experts include Erik Sorem Anderson, MD, clinical instructor in the department of emergency medicine at Stanford University in Palo Alto, and attending physician in the department of emergency medicine at Highland Hospital in Oakland Calif.; Kirk Dombrowski, PhD, John G. Bruhn Professor of Sociology and director of the University of Nebraska at Lincoln Minority Health Disparities Initiative; Camila Gelpi-Acosta, PhD, an assistant professor of criminal justice at the City University of New York and supporter of El Punto en la Montaña, a grassroots syringe exchange program in Puerto Rico; Mark Hull, MD, a clinical associate professor at University of British Columbia, and research scientist at the BC Centre for Excellence in HIV/AIDS; and Julio Montaner, MD, DSc, Director of the BC Centre for Excellence in HIV/AIDS.

Q: How can HCV specialists best work with addiction centers to bring potential patients into more complete and comprehensive HCV care?

Anderson: When it comes to HCV screening and referral for treatment, we need to think outside the box for PWID. This population is more likely to use non-traditional venues for their care and is less likely to be engaged in regular and preventive care. That means screening also needs to take place outside traditional screening venues. Screening in EDs, addiction clinics, needle exchanges, and in jails should all be considered, if resources allow. While some of these non-traditional venues have integrated HCV or HIV testing, it is definitely the exception. Many of these places are already stretched thin, and the implementation of a screening program for HCV will likely require additional staff and funding.

There is enormous potential in HCV screening and treatment for PWID, though there are going to be challenges along all steps of the cascade of care. This population has competing social and economic factors that make linkage to care difficult. We need to work closely with social workers, substance abuse counselors and primary care doctors to connect these patients with HCV specialty care. These non-traditional venues for HCV screening may have a high prevalence of PWID compared to primary care clinics. However, the clinicians working in these venues often have less experience with screening. This requires buy-in from staff and likely a higher utilization of resources than would ordinarily be used for public health screening.

Dombrowski: In terms of complete and comprehensive care, there are a number of new drugs on the market that have radically changed the way HCV can be treated. This presents a very quickly changing environment, depending on the price points these drugs come in on and Medicaid coverage in states. It is a fluid situation that varies a lot, from places on the east coast to a situation like the one we see in Puerto Rico. That said, there are a couple things to keep in mind.

Often people who are on opiate substitution treatment like methadone continue to use opiates outside of treatment. It is not uncommon for PWID to continue to inject. One thing we can do in working with addiction centers is use the face-to-face contact as an opportunity to encourage people to use HCV-safe injection procedures outside of their treatment. Many places in the U.S. have working forms of syringe exchange programs, which have done a lot to bring down HIV rates. But patients continue to share works, cookers, water and cotton. These factors are much riskier for HCV than they are for HIV because of the higher infectivity. We need to use addiction centers as a point of contact to practice prevention in a comprehensive injection scenario.

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Gelpi-Acosta: One approach is to offer a comprehensive service portfolio that is not limited to the actual HCV treatment. This can include syringe exchange. For those who are still injecting drugs, a $0.07 syringe helps prevent reinfection and transmission. Opioid substitution therapy with buprenorphine or methadone can also be helpful. Instruction about safe injection facilities, which has been proven in Australia and Canada to help prevent overdoses, injection paraphernalia sharing, etc. is another approach.

The operative concept here is comprehensiveness of services. One bullet does not fix all. Their lives are indeed quite complicated, and they need medical, public health, and social services that can handle that complexity. It is a known fact that PWID carry the burden of HCV in every developed nation. Services for PWID must embrace their lives’ complexities by incorporating into their HCV treatment syringe exchange services and safe injection facilities. The latter are cost-effective mechanisms to reduce HCV incidence and prevalence.

Q: What talking points need to be covered differently when treating CV in a PWID?

Anderson: From the perspective of HCV screening, we need to reduce stigma. Some, especially if HCV screening is new, may question why we should screen PWID because “they won’t get treated anyway.” In our ED, this is easily overcome with education and examples of patients who have successfully completed treatment.

Gelpi-Acosta: The first talking point is active drug use. But we should not judge their drug use. All you are doing with that is guaranteeing they do not come back for treatment. They, like most people, avoid being judged. Talk about drug use, and even about the lack of drug use as an ideal physiological environment, but do not tell them they must stop using drugs to be worthy of HCV treatment. That is an old-fashioned approach, even for medical standards, and flat-out inhumane. It is also inaccurate, as a plethora of studies have demonstrated sustained virologic response in PWID.

The second talking point is reinfection. If active injection drug use is still the case, the importance of not sharing any injection paraphernalia such as syringes, needles and/or chambers, cookers, tourniquets, drug-filtering cloths/cottons, water, etc., must be highlighted. We need to provide these patients with these tools so they won’t share any of these. Syringe exchange programs are close to eliminating HIV transmission among PWID in New York City precisely because PWID care about their health and use these resources.

Dombrowski: The risk for reinfection is a high one. We recognize that even people who spontaneously clear once are not necessarily more likely to spontaneously clear in the future. This has a lot to do with genotypic variety of the virus. Something different among PWID is that they remain at risk even if they clear. Even if they are cured, they still carry risk.

The second thing is that, for various economic reasons, even if they exchange syringes, they still share other parts of works. In Puerto Rico, while syringe sharing has mostly slowed or stopped, even in rural areas, continued sharing of other paraphernalia puts them at risk.

Q: How can we best ensure adherence to therapy in this population?

Hull: Adherence is an important component of providing HCV care in any setting. A number of strategies have been used successfully in PWID, including linking HCV medications to other medication programs such as methadone/opiate substitution therapies (OST) or antiretrovirals (both of which are often delivered in a daily fashion, and can be witnessed), dispensing medications in blister packs and involving adherence supports, such as HCV treatment groups or peer support programs.

Dombrowski: This depends on which kind of therapy we are discussing. Current treatments are obviously quite different from interferon. The classic barriers to adherence with interferon-based therapy included length of treatment and physical discomfort with the drug. The key to adherence with interferon, then, is the contact support people for patients taking it. When patients were partway through the treatment, they would need continued outreach and assistance.

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For the newer drugs, the real question is whether they can afford them. Adherence has become a financial issue. People need to maintain sufficient regular contact to allow for the medications to be stable and balanced, but the biggest thing to ensure adherence is to work with Medicaid delivery services to make sure the pills are paid for and covered.

Gelpi-Acosta: Adherence when you are a PWID is a matter not just of biology but of the level of trust between patient and doctor. This relationship needs to be healthy and non-judgmental if adherence is to be achieved.

Montaner: Over the next few years, the BC Centre for Excellence in HIV/AIDS will be actively investigating how to improve engagement and adherence in treatment for hepatitis C. In this context, we have received a grant from our provincial government to monitor and evaluate the overall impact of the ongoing roll-out of HCV therapy in British Columbia, and to establish a prospective research cohort of individuals successfully treated for HCV, to characterize HCV reinfection rates among populations at increased risk for reinfection (eg, PWID, people living with HIV, men who have sex with men, etc.). We will also aim to determine the threshold of risk reduction engagement that minimizes the likelihood of HCV reinfection.

Q: How do you manage competing health care priorities in PWID?

Hull: This is always a challenge! PWID have many competing priorities in terms of stabilizing addictions and mental health, but also social challenges such as food security, housing and safety. Fitting HCV into the picture can be difficult, particularly as people may not feel unwell. The result is that HCV can slip down the priority list. We have found, however, that HCV can often be a driver for improving engagement in overall care. People get excited about the possibility of curing this infection. Entry into multidisciplinary care programs for HCV can then serve to link them to general care.

We need to balance these competing priorities, but we don’t want HCV to be left too late because that is when HCV-related complications tend to develop.

Montaner: Creating access points to care is very important to addressing the overall needs of PWID. When addressing hepatitis C in this setting, it is critically important to provide wrap-around services to support harm reduction so that we minimize the likelihood of HCV reinfection.

Gelpi-Acosta: Since PWID carry the burden of HCV, it is only logical that treatment should be particularly tailored for them. Health insurance companies that limit coverage to people who do not drink alcohol and/or use illicit drugs are not coming to those decisions because it is medically sound. To the contrary, the opposite is known to be medically sound.

On April 27, 2016, New York State instructed six different insurance companies to cease this practice, and gave them 45 days to begin covering treatment for PWID. This should be the case everywhere, including Puerto Rico, where as many as 90% of PWID might be HCV-infected. In Puerto Rico, unless you are HIV co-infected, you are not eligible for any type of HCV treatment, and that includes the old fashioned interferon/ribavirin. This is a perfect example of a counter-public health policy.

Anderson: In the ED, we should be taking a more comprehensive approach to this population. For example, when a patient who injects drugs presents to the ED, they should have a brief intervention and assessment of their addiction, HIV and HCV screening, a referral to addiction medicine, and consideration of harm reduction measures, including naloxone distribution and medication-assisted therapy and needle exchanges. We should also be thinking about social needs such as housing and transportation that may impede their engagement in outpatient care.

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This may seem like an additional burden when dealing with their acute/emergent medical complaint, and providers should use their judgment as to what is appropriate. Providers who work in environments with high numbers of PWID do have a unique opportunity to have a public health impact, and a little additional effort can often be worked smoothly into clinical care.

Q: How serious is the threat of reinfection in PWID? What can clinicians do to prevent it? And to what extent should HCV specialists be dealing with addiction?

Montaner: Harm reduction, coupled with better access to addiction medicine treatments, and expanded HIV testing and treatment, has led to a 90% decrease in AIDS cases and HIV mortality among HIV-infected injection drug users in BC. Further, our research has found that people who use Vancouver’s supervised injection site, called Insite, are 30% more likely to enter detox programs and 70% less likely to share needles.

Hull: Most HCV specialists are aware of addiction, so it is more a question of how care is delivered. Shared care with an OST provider is best, and better if that provider is on the same team or in the same facility. It may also be beneficial to involve more primary care teams that are trained to offer both with specialist advice.

Reinfection is a reasonable concern. There is a growing body of data to show that rates of reinfection over a 5-year period can be higher than those in non-PWID populations. It may be as high as 8% over 5 years in some reviews. Engagement in harm-reduction strategies is critical to help minimize risk activities such as needle sharing, and overall addictions care is critical.

Dombrowski: That’s a really difficult question. Findings from the National Institute on Drug Abuse show that our ability to treat drug abuse is now on par with the level of management of diabetes and other chronic conditions. We are seeing high success rates. But overall, given that the needs for preventing HCV infection are pretty clear even in people who use drugs, energy spent dealing with transmission risk is better than spending time dealing with addiction. For HCV specialists, it is better to spend time talking about HCV-specific issues than to deal with addiction. HCV specialists are not cut out for dealing with addiction. If anything, HCV specialists should use their contact to encourage people to stay in addiction programs.

Montaner: Optimizing access to addiction medicine and harm reduction services are critically important in the context of treating HCV among PWID. In the absence of such services, HCV cured PWID are at very high risk of reinfection.

Through the Goldcorp/St. Paul’s Hospital Addiction Medicine Fellowship in Vancouver, we are increasing capacity to accommodate in evidence-based addiction medicine and harm reduction services in British Columbia.

Q: What follow-up is necessary for a PWID, and how is this different from your mainstream patient?

Hull: We tend to spend a bit more time in terms of getting a plan in place for medication delivery and adherence. It is also important to plan to actively and regularly check in during treatment. Again, some of the group models can be helpful here. Afterwards, due to concerns about reinfection it is important to be sure they are connected with harm reduction programs or OST. Follow-up laboratory monitoring is also important.

Dombrowski: Because PWID continue to be at elevated risk as long as they are using drugs, the need for follow-up is much greater to reduce reinfection risk. There needs to be a more focused and robust form of follow-up. Clinicians should continue to press these patients on questions of equipment sharing. This would be a primary care visit question. We should take every opportunity to find out if they are still using, whether they are making accommodations to have clean equipment and make them recognize they are susceptible to reinfection. In ongoing health care visits, HCV- and addiction-specific questions need to be more aggressive.

Montaner: We are currently setting up a prospective cohort to evaluate long term outcomes among successfully treated HCV-infected PWID in British Columbia, to establish the rate of reinfection, and the level of engagement in harm reduction and addiction medicine services associated with protection against reinfection.

For more information:
Erik Sorem Anderson, MD, can be reached at Department of Emergency Medicine, Stanford University, 300 Pasteur Drive, Palo Alto, CA, 94304; email: esoremanderson@gmail.com.
Kirk Dombrowski, PhD, can be reached at Department of Sociology, Oldfather Hall, Room 711, University of Nebraska-Lincoln, Lincoln, NE 68502; email: kdombrowski2@unl.edu.
Camila Gelpi-Acosta, PhD, can be reached at 31-10 Thomson Avenue, Long Island City, NY 11101 (Office C-459-VV); email: camilagelpi@gmail.com.
Mark Hull, PhD, can be reached at B.C. Centre for Excellence in HIV/AIDS,608–1081 Burrard Street,Vancouver, BC, Canada, V6Z 1Y6; email: mhull@cfenet.ubc.ca.
Julio Montaner, MD, DSc, can be reached at B.C. Centre for Excellence in HIV/AIDS608–1081 Burrard StreetVancouver, BC, Canada, V6Z 1Y6; email: cdobuzin@cfenet.ubc.ca.

Disclosures: Anderson reports no relevant financial disclosures. Dombrowski reports no relevant financial disclosures. Gelpi-Acosta reports no relevant financial disclosures. Hull reports honoraria paid to his institution for speakers engagements from AbbVie, Bristol-Myers Squibb, Gilead, Merck, Janssen and Viiv. Montaner reports no relevant financial disclosures.