Hepatitis C in European prisons: a call for an evidence-informed response.

Globally, over 10 million people are held in prisons and other places of detention at any given time. People who inject drugs (PWID) comprise 10-48% of male and 30-60% of female prisoners. The spread of hepatitis C in prisons is clearly driven by injection drug use, with many infected prisoners unaware of their infection status. Risk behaviour for acquisition of hepatitis C via common use of injecting equipment is widespread in many prison settings. In custodial settings, effective and efficient prevention models applied in the community are very rarely implemented. Only approximately 60 out of more than 10,000 prisons worldwide provide needle exchange. Thus, HCV prevention is almost exclusively limited to verbal advice, leaflets and other measures directed to cognitive behavioural change. Although the outcome of HCV antiviral treatment is comparable to non-substance users and substance users out of prison, the uptake for antiviral treatment is extremely low. Based on a literature review to assess the spread of hepatitis C among prisoners and to learn more about the impact for the prison system, recommendations regarding hepatitis C prevention, screening and treatment in prisons have been formulated in this article.

Enhancing assessment and treatment of hepatitis C in the custodial setting.

Acute and chronic hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. This disparity between the burden of disease and hepatitis service delivery reflects the marginalized patient population, which features high rates of injection drug use and poor mental health. In addition, the prison environment is intended for deprivation of liberty and not healthcare. Screening for HCV infections is provided in most jurisdictions, but uptake rates remain low. Assessment and treatment of inmates is often provided only by community-based services. Despite these challenges, assessment and treatment of inmates with chronic HCV via prison-based services has been shown to be feasible and effective. These services offer the potential to substantively increase HCV treatment uptake and reduce the burden of disease for the community at large. Improvements in the efficacy of HCV therapies via direct-acting antivirals, which also offer reduced treatment duration and decreased toxicities, mean that prison health services will be well placed for the treatment of large numbers of people with HCV who do not access health services in the community.

Recommendations for the management of hepatitis C virus infection among people who inject drugs.

In the developed world, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). The burden of HCV-related liver disease in this group is increasing, but treatment uptake among PWID remains low. Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment. Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new treatments for HCV infection become available.

Chronic Hepatitis C Treatment in Patients with Drug Injection History: Findings of the INTEGRATE Prospective, Observational Study.

INTRODUCTION: People who inject drugs represent an under-treated chronic hepatitis C virus (HCV)-infected patient population. METHODS: INTEGRATE was a prospective, observational study investigating the effectiveness, safety, and adherence in routine clinical practice to telaprevir in combination with peg-interferon and ribavirin (Peg-IFN/RBV) in patients with history of injecting drug use chronically infected with genotype 1 HCV. RESULTS: A total of 46 patients were enrolled and included in the intent-to-treat (ITT) population. Among heroin and/or cocaine users (n = 37; 80%), 22% reported use in the past month; 74% (34/46) of patients were on opioid substitution therapy in the pre-treatment phase, and 43% (20/46) discontinued HCV treatment prematurely. Sustained virologic response rate was 54% (25/46) in the ITT population and 74% (25/34) in the per protocol (evaluable-for-effectiveness) population. The main reason for failure in the ITT analysis was loss to follow-up (n = 8; 17%). Adverse events occurred in 91% (42/46) of patients. Mean patient-reported adherence to study drugs was >89% at Week 4, Week 12 and end of treatment. CONCLUSION: Despite a high rate of treatment discontinuation (including loss to follow-up), self-reported adherence to treatment was good and virologic cure rates were similar to those reported in large real-world cohorts. Our findings suggest that people with a history of injecting drug use should be considered for treatment of chronic HCV infection, and highlight the need for improvements in patient support to boost retention in care and, in turn, help to prevent reinfection and transmission. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT01980290. FUNDING: Janssen Pharmaceuticals.

Pilot Study: Combining Formal and Peer Education with FibroScan to Increase HCV Screening and Treatment in Persons who use Drugs.

BACKGROUND: Treatment uptake for hepatitis C virus (HCV) infection remains low in persons who inject drugs (PWID), due to lack of knowledge and low perceived need for treatment. Therefore, we conducted a pilot study to assess the influence on knowledge and willingness for HCV screening and treatment among persons who use drugs (PWUD) by combining formal and peer education with FibroScan measurement. METHODS: Clients of the Center for Alcohol and other Drug problems (CAD) in Limburg (Belgium) were randomized into a control group, which received the standard of care, and an intervention group, which received an innovative combination of formal and peer education followed by FibroScan. Knowledge of HCV infection and willingness for screening and treatment were evaluated at baseline, after intervention and 1 and 3months after intervention by means of questionnaires. RESULTS: Baseline knowledge was similar for the control (n=27) and the intervention group (n=25) (58 vs. 59%; p=0.67). Immediately after the information session, knowledge increased to 86% (p<0.001) in the intervention group. After 3months, knowledge decreased significantly (69%; p=0.01). No significant changes in knowledge were found in the control group. Baseline willingness for treatment was 81% in both the control and intervention groups, but after 1 month decreased in the control group (44%) and remained stable in the intervention group (75%). Differences in actual screening uptake between the control and intervention group were not significant (7% vs. 20%). Four percent of the intervention group and no one in the control group started treatment. CONCLUSION: The small number of subjects should be considered when interpreting the results of this study. In brief, the single information session significantly improved HCV knowledge among PWUD, but did not result in a higher uptake for screening and treatment. This could signify that there are other important reasons, besides lack of knowledge, not to undergo screening or start treatment. The fact that knowledge decreased after 3months indicates that it would be beneficial to repeat the information session regularly.

Eligibility of persons who inject drugs for treatment of hepatitis C virus infection.

In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.