Enhancing engagement in hepatitis C care among people who inject drugs

Reducing barriers to hepatitis C-related care requires us to strategically target opportunities at each health level in order to facilitate engagement among people who inject drugs (PWID). To this end, it is also critical that we understand more clearly what is meant and expected by health-care engagement among PWID. The development of interferon-free, direct-acting antivirals (DAAs) has brought forth world-wide momentum to meet World Health Organization (WHO) 2030 targets to eliminate hepatitis C virus (HCV) as a global public health threat 1. Reaching people who inject drugs (PWID) is a necessity, given that this population group is most affected by HCV (in high-income countries) and has low treatment uptake overall 2. In the interferon-based era, clients were required to receive HCV-related care from a specialist (e.g. gastroenterologist, hepatologist, infectious disease specialist), often in a hospital-based setting which, due to well-documented barriers, including stigma and marginalization, most PWID did not access and complete 3. The new DAA era, in contrast, has resulted in many countries permitting HCV management outside of hospital-based care—a propitious time to improve health-care engagement with PWID. How can we make the most of this opportunity? First, we must address a consistently neglected issue: what is 'health-care engagement' beyond clinical end-points or current measures of health service activity (e.g. the number of times a service has been accessed, the number of services an individual has attended)? Understanding meaningful engagement from the point of view of PWID, including which elements of engagement are key to facilitating access to care and achievement of client goals, is of urgent concern 4. Peer-based services and approaches in the design and delivery of HCV-related care would more clearly solidify engagement expectations between PWID and practitioners 5. For example, some PWID require more upfront care than practitioners anticipated in the new DAA era of minimal side effects and cure responses greater than 95% 6. Poor venous access remains a barrier to HCV testing (and, hence, treatment initiation), and although advancements in testing alternatives are promising these have yet to be implemented on a wide scale. Further, some PWID who have received HCV RNA confirmatory testing remain reluctant to initiate treatment. Highlighting the long-term impact of HCV infection on liver health is especially important among PWID who do not report any HCV-related symptoms 7, 8. Increased input from PWID, peer workers and community groups on how best to engage PWID in the earlier states of the HCV care cascade is crucially needed to inform models of care. Post-DAA care is another critical juncture for engagement. Ongoing education on liver health and safe injection practices are paramount to maintaining beneficial health outcomes following HCV treatment 7, 9. It is unclear how frequent, or widespread, such discussions are between PWID and practitioners and, importantly, whether PWID are being directed to harm reduction services when applicable (e.g. needle and syringe programmes). As above, the increased use of peer-based approaches provides PWID with the support to discuss 'sensitive' topics with practitioners, if desired, as well as access to information and services in a non-judgemental space. At the practitioner level, the removal of DAA reimbursement restrictions has broadened the once-specialized HCV field, allowing primary health-care practitioners to prescribe DAAs 10, 11. Some practitioners have stated an unwillingness to offer treatment to PWID due to adherence concerns 12. This is problematic for several reasons, including being unethical. Evidence demonstrates that high cure responses among PWID, and also widespread treatment uptake, will help to reduce onward HCV transmission 13. Given this, clinics should be appraised by the federal/state ministry on their ability to engage PWID in HCV care. At the structural level, increased engagement of PWID in HCV care would be facilitated by greater synergy among alcohol and other drug (AOD), mental health and primary care sectors. A perception held by some AOD centres during the interferon-based era was that HCV treatment was not part of 'core business' and should not be incorporated into clinical care 16. Interferon-free DAA therapies are safe and easy to administer and should be widely delivered in settings that have a high proportion of PWID clients. The navigation of multiple services and their paperwork between health sectors can be a cumbersome undertaking for both clients and practitioners, even when services are purportedly closely affiliated, such as those for infectious disease and AOD. Providing as many 'in-house' services as possible will diminish some PWID barriers to the HCV-related care cascade 17. Outreach to homeless centres and needle and syringe programmes could further help to identify cases of HCV infection among PWID who do not access health-care settings regularly 18, 19. Following the initial wave of clients who received interferon-free DAA treatment when first listed, it is postulated that PWID yet to initiate treatment have a greater likelihood of entrenched marginalization and comorbidities. Health system modifications require a country-specific response based on multiple factors (e.g. level of HCV burden, health financing) and, with this, strategies that will build capacity among practitioners. Expertise from the AOD sector will be key to optimizing engagement with PWID populations as well as streamlining HCV care and delivery 14. Practitioners new to the field of HCV treatment would benefit from the extensive knowledge and networks of the AOD field, e.g. their established referral pathways with community-based pharmacists. Increased opportunities for interdisciplinary collaborations must thus be initiated and supported by ministries. In the new DAA era, improved engagement in HCV care necessitates a clearer understanding of what engagement means to PWID. It is not sufficient to decry a lack of patient motivation and dismiss long-standing, entrenched barriers at every level of the health sector. The road to HCV elimination demands a more purposeful, inclusive approach; one that will more holistically address and actively include PWID in its response. C.T. has received speaker fees from AbbVie and Gilead Sciences. A.D.M. and A.M. have no interests to declare. A.D.M. holds a postdoctoral fellowship that is partly supported by the Canadian Network on Hepatitis C (Canada).

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