Hepatitis C has a cure. Yet the bloodborne virus causes hundreds of thousands of preventable deaths around the world every year, and structural barriers in the health care system prevent the most at-risk population—people who inject drugs—from accessing testing and treatment.
A March study published in The Lancet Regional Health — Americas highlights one particular strategy that could dramatically improve hep C treatment access for people who use opioids. The randomized controlled trial found that when people enrolled in opioid treatment programs (OTP) were offered hep C treatment on-site at those same programs, they were nearly four times more likely to initiate it compared to people who were given off-site referrals.
Though the likelihood of patients completing the regimen and confirming they’d been cured was similar, the higher uptake in the OTP route would mean more people getting cured. The study is the first randomized controlled trial in North America to compare the two methods.
“[W]e’re able to show that integrating hepatitis C testing and treatments into OTPs transforms the hepatitis C care cascade,” lead author Dr. Oluwaseun Falade-Nwulia, an associate professor at the Johns Hopkins School of Medicine, told Filter.
Falade-Nwulia said this involved first training OTP providers to deliver hep C care to their patients. Next, finding people with lived experience to offer peer support through the treatment process.
Among patients offered on-site hep C treatment at OTP—commonly known as methadone clinics—nearly nine out of 10 initiated it. Only two out of 10 initiated care treatment through an offsite referral. After nine months, 61 percent of participants in the on-site treatment group had been cured of hepatitis C, compared to just 14 percent in the referral group.
Hepatitis C treatment does not require abstinence from substance use.
A decade ago, hep C treatment was revolutionized with the arrival of direct-acting antiviral (DAA) medications, which replaced interferon-based therapy. Interferon injections had to be administered every few days for the better part of a year, came with severe side effects and ultimately had a low success rate. DAA are oral medications, often taken for just eight weeks, that almost never cause any side effects and have a 95-percent success rate. And, critically, DAA do not require abstinence from substance use, which was a barrier with interferon.
Falade-Nwulia lamented that hep C is “still such a major public health issue,” when strategies like on-site treatment at OTP could have such a big impact. But what may seem like a straightforward intervention becomes complicated by the health care industry.
Hep C treatment is extraordinarily expensive, and so patients must first be enrolled in insurance that will cover it. In many states, patients must obtain prior authorization from Medicaid before they can receive DAA—a process that can delay care or discourage providers from offering it altogether. Seventeen states currently impose some form of prior authorization requirement. So hep C continues to spread among those least able to access treatment.
“The way OTP reimbursement is structured currently in the US limits the ability of the OTP to get additional compensation for providing this additional service,” Falade-Nwulia said. “I think we really do need policy change to provide additional support to OTPs to be able to integrate this care in their settings.”
“This is just such a low-barrier, low-threshold approach.”
One clear advantage of the OTP strategy is that it leverages existing infrastructure, upskilling staff and peers to support patients more effectively. It is not a complex or high-tech intervention, and it may be one of the most effective.
“This is just such a low-barrier, low-threshold approach,” Falade-Nwulia said. “I think the additional cost at the system level is significantly outweighed by the potential benefit, both to the people accessing services at these OTPs and the larger society that will be protected from ongoing transmission of hepatitis C.”
Still, Falade-Nwulia said that scaling this model will require addressing significant policy and financial barriers. The study demonstrated what is possible under ideal conditions; such a high level of support isn’t typically available in OTP programs. AbbVie Inc., which funded the study, also provided the DAA—sidestepping the insurance hurdles that bar so many low-income people from treatment. Abbvie manufactures Mavyret, one of the most widely used DAA.
“In states that still have prior authorization requirements for Medicaid approval of hepatitis C treatment, it will be critical to have [them] removed for OTPs to even begin to consider integrating hepatitis C treatment into their routine care,” Falade-Nwulia said.
Image (cropped) via New York State Department of Health