Research paper
Injecting risk behaviours following treatment for hepatitis C virus infection among people who inject drugs: The Australian Trial in Acute Hepatitis C

https://doi.org/10.1016/j.drugpo.2015.05.003Get rights and content

Highlights

  • There is a concern that HCV treatment may increase injecting risk behaviours.

  • HCV treated and untreated participants were followed for a median of 1.8 years.

  • Association between HCV treatment and injecting risk behaviours was assessed.

  • HCV treatment was not associated with injecting drug use or used needle and syringe borrowing.

  • HCV treatment was associated with decreased ancillary injecting equipment sharing.

Abstract

Background

A barrier to hepatitis C virus (HCV) treatment among people who inject drugs (PWID) has been a concern that interferon-based HCV treatment may increase injecting risk behaviours. This study evaluated recent (past month) injecting risk behaviours during follow-up among PWID that did and did not receive HCV treatment.

Methods

The Australian Trial in Acute Hepatitis C (ATAHC) was a prospective study of natural history and treatment of recent HCV infection. Analyses were performed using generalized estimating equations.

Results

Among 124 participants with a history of injecting drug use (median age 32 years), 69% were male, and 68% were treated for HCV infection. HCV treatment was not associated with an increase in recent injecting drug use (adjusted odds ratio (aOR) 1.06, 95% CI 0.93, 1.21) or recent used needle and syringe borrowing during follow-up (aOR 0.99, 95% CI 0.89, 1.08). HCV treatment was associated with a decrease in recent ancillary injecting equipment sharing during follow-up (aOR 0.85, 95% CI 0.74, 0.99). Further, among treated participants who remained in follow-up (n = 24), ancillary injecting equipment sharing significantly decreased from 54% at enrolment to 17% during follow-up (P = 0.012).

Conclusions

HCV treatment was not associated with drug use or used needle and syringe borrowing during follow-up, but was associated with decreased ancillary injecting equipment sharing during follow-up. Programs to enhance HCV assessment and treatment among PWID should be expanded, given that HCV treatment does not lead to increases in injecting risk behaviours and has previously been demonstrated to be safe and effective among PWID.

Introduction

The prevalence of hepatitis C virus (HCV) infection is high among people who inject drugs (PWID), ranging from 64 to 94%, globally (Hajarizadeh et al., 2013, Nelson et al., 2011). HCV infection is a major cause of morbidity and mortality among PWID (Dore and Grebely, 2011, Grebely and Dore, 2014). Interferon-based HCV treatment is safe and effective among people with a history of injecting drug use (Dimova et al., 2013, Hellard et al., 2009) and those who actively inject drugs (Aspinall et al., 2013). International guidelines now recommend HCV treatment for PWID (European Association for the Study of the Liver, 2011, Ghany et al., 2009, Grebely et al., 2015, Robaeys et al., 2013). However, HCV treatment uptake remains suboptimal among PWID (Alavi et al., 2014, Grebely et al., 2009, Iversen et al., 2014, Mehta et al., 2008, National Centre, 2014), due to several barriers at the levels of system, providers and patients (Grebely and Dore, 2014, Grebely et al., 2013, Grebely et al., 2010). Concerns of ongoing drug use or relapse to drug use during interferon-based antiviral therapy among practitioners have contributed to low HCV treatment uptake in this population (Grebely et al., 2013).

A recent meta-analysis among people with a history of injecting drug use has demonstrated similar rates of treatment success, compared to responses obtained in registration trials in the general population (Dimova et al., 2013). Similarly, a recent systematic review among people who reported active drug use has shown acceptable HCV treatment outcomes, high treatment adherence and low treatment discontinuation in this population (Aspinall et al., 2013). Earlier studies have shown that HCV treatment is safe among people receiving opioid substitution treatment (OST) and does not increase drug use (Mauss et al., 2004, Sasadeusz et al., 2011, Van Thiel et al., 2003). However, recent data on drug use behaviours following initiation of HCV treatment among PWID is scarce. The availability of interferon (IFN)-free direct acting antiviral (DAA) therapies (Dore & Feld, 2015) will likely lead to an expansion of treatment among PWID. As such, a better understanding of the impact of HCV treatment on drug use and injecting behaviour is needed to inform clinical decision making in this area. This is particularly important because some clinicians often withhold therapy from PWID, given unfounded concerns that the side effects of interferon-based HCV treatment may mimic opioid withdrawal or lead to depression, thereby leading to a relapse to injecting drug use or increase injecting risk behaviours (Myles, Mugford, Zhao, Krahn, & Wang, 2011).

The Australian Trial in Acute Hepatitis C (ATAHC) was designed to investigate treatment for recent HCV infection, predominantly in those with injecting drug use-acquired infection. The aim of this study was to evaluate recent injecting risk behaviours during follow-up among people with a history of injecting drug use and recent HCV infection enrolled in the ATAHC study that did and did not receive HCV treatment.

Section snippets

Design, setting and participants

ATAHC was a multicentre, prospective cohort study of the natural history and treatment of recent HCV infection, as previously described (Dore et al., 2010). Study recruitment occurred from June 2004 to February 2008 through an Australian network of tertiary hospitals (n = 13) and general practice/primary care clinics (n = 3).

Inclusion criteria for the study required recent HCV infection (acute or early chronic HCV infection), defined as first positive anti-HCV antibody within 6 months of enrolment

Participant characteristics

Among 163 enrolled participants (Dore et al., 2010), 124 (76%) with a history of injecting drug use were included in this analysis. Compared to those without a history of injecting drug use (n = 39), participants with a history of injecting drug use were younger, less often had full-time or part-time employment, had poorer social functioning and less often had HCV/HIV co-infection (Supplementary Table 1).

Among those with a history of injecting drug use (n = 124), the median age was 32 years (IQR

Discussion

In this study of PWID with recently acquired HCV, interferon-based HCV treatment was not associated with an increase in injecting drug use or needle and syringe borrowing during follow-up. However, HCV treatment was associated with a reduction in ancillary injecting equipment sharing during follow-up. These results should address concerns by some practitioners that HCV treatment may lead to an increase in drug use risk behaviours (Grebely et al., 2013, Schaefer et al., 2013). Programs to

Declaration of interest

Gail Matthews has received travel grants and research support from Roche, Gilead and MSD. Gail Matthews has been on advisory board for Gilead. Gail Matthews has received travel support from BMS. Gail Matthews has received research support from Janssen. Paul Haber is on an advisory board for Lundbeck Pharmaceuticals. Paul Haber has been paid by Roche to give presentations. Barbara Yeung has received travel grants from Roche. Kathy Petoumenos has received a travel grant from ViiV Healthcare.

Clinical trials registration details

The study was registered with clinicaltrials.gov registry (NCT00192569).

Funding

The Kirby Institute is funded by the Australian Government Department of Health, under the agreement ID number 2-D3X513. The views expressed in this publication do not necessarily represent the position of the Australian Government. Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award R01DA015999. The content is solely the responsibility of the authors and does not necessarily represent the official views of

ATAHC Study Group

Protocol Steering Committee members:

John Kaldor (Kirby Institute), Gregory Dore (Kirby Institute), Gail Matthews (Kirby Institute), Pip Marks (Kirby Institute), Andrew Lloyd (UNSW), Margaret Hellard (Burnet Institute, VIC), Paul Haber (University of Sydney), Rose Ffrench (Burnet Institute, VIC), Peter White (UNSW), William Rawlinson (UNSW), Carolyn Day (University of Sydney), Ingrid van Beek (Kirketon Road Centre), Geoff McCaughan (Royal Prince Alfred Hospital), Annie Madden (Australian

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      Therefore, it is the opinion of the authors that the selected studies rate more highly for study design appraisal. Four studies investigated the impact of treatment on past month injecting drug use at various time points during treatment and follow up, assessed dichotomously (Alavi et al., 2015; Artenie et al., 2017; Artenie et al., 2019; Midgard et al., 2017). Alavi et al. (2015) reported no association between HCV treatment and past month drug use during 24 weeks follow up, when comparing PWID who did and did not receive treatment (aOR 1.06, 95% CI 0.93–1.21, n = 124).

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    These authors contributed equally to this work.

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