HCV care must ‘move away from the ivory tower’ to achieve elimination

WASHINGTON — A decentralized, integrated care model is necessary to eradicate hepatitis C virus in hard-to-reach populations, including among individuals who use drugs, according to a presenter at The Liver Meeting.

“If we are to achieve HCV elimination, we need to move away from the ivory tower hepatologist model of care,” Sumita Verma, MBBS, MD, FRCP, professor of hepatology at Brighton and Sussex Medical School in England, said during her presentation. “We need to move towards decentralized, integrated model, and we have shown in this study that such a model is associated with high service uptake.”

Verma presented 8 years of prospective data showing how the community-based Integrated-Test-Stage Treat (ITTREAT) project — a decentralized, nurse-driven model — achieved high sustained virologic response rates among people who use drugs (PWUD) and that holistic treatment further benefited cure rates.

ITTREAT included two distinct periods: period one from 2013 to 2017 and period two from 2017 to 2021. The project, based in an addiction center, ran as a “one-stop service” in which providers had point-of-care dry blood spot testing, transient elastography, HCV treatments, opioid antagonist treatments (OAT) and psychiatric consultation. Care also included peer mentors and contingency management such as food vouchers and delivery of medication to homeless hostels or individual homes.

Verma reported on 754 individuals recruited through ITTREAT, of whom 65% (n = 490) had positive HCV antibodies. Of those, 84% (n = 413) were HCV RNA positive and most (n = 405) were eligible for treatment.

At baseline, Verma noted significant differences between individuals in the cohort from period one to period two: Current or past injection drug use (IDU) was reported in 72% of those in period one vs. 90% in period two; homelessness at initial assessment in 50% vs. 67%, respectively; receipt of OAT in 52% vs. 75%; overdose history in 31% vs. 71%; any psychiatric diagnosis in 50% vs. 84%; and at least one comorbidity in 25% vs. 44% (all P < .001).

“There was no doubt that the individuals that we recruited in the second half of the study were clearly more complex,” Verma said.

Three hundred individuals received HCV treatment and 272 of those received direct-acting antivirals (DAAs). Of the 270 for whom treatment outcomes were available, 86% (n = 232) achieved SVR.

Of the 38 individuals who did not achieve SVR, 25% were true virological failures, Verma said. Half (n = 19) were non-adherent and 25% were lost to long-term follow-up.

“Once we plug in adherence into our model, there were only two independent predictors of not achieving SVR12 and that was not being on OAT and having less than 80% adherence,” Verma said.

Those who received OAT had an 89% SVR vs. 78% in those who did not receive OAT (P = .029), while those who had at least 80% adherence had a 93% SVR vs. 16% in those who had less than 80% adherence (P < .001).

Even with a more complex patient cohort in period two, Verma reported no significant difference in overall SVR rates.

“Again, this confirms that the actual slightly lowish SVR rates in these individuals is not because of true virological failures but because of other reasons,” she said.

Verma also reported overall reinfection rates (7.5%) and mortality (12%).

“It was quite alarming,” she said. “In the treated cohort, the mortality was even higher — it was 15%, of whom 73% had actually achieved sustained virological response. We are still looking at the causes of death, but where the cause of death is available, i< rel="noopener noreferrer"a href="https://www.healio.com/news/psychiatry/20220728/overdose-rate-will-continue-to-grow-its-going-to-mean-mass-death" target="_blank">nvariably it was linked to drug overdose in this cohort who were treated.”

She continued, “We were concerned by the high mortality rate, and I think this needs to be addressed and I think certainly in this complex ... population, you probably need to be thinking beyond just HCV cure.”