November 10, 2013

Provided by Clinical Car5e Options

Gregory Dore, - 9/24/2013 More from this author

Need and the greater good should drive healthcare decision making. As a consequence, we must never forget that behind a needle and spoon, there is a human being in need. Human frailty, personal choices, and politics aside, people who inject drugs (PWID) represent a segment of the population that, with understanding and the will to act, can be successfully treated for hepatitis C. However, to achieve the goal of successful treatment, healthcare providers must first create a nonjudgmental environment to overcome the reluctance of PWID to report their drug use. By allowing them to open up to us as providers, we establish a foundation of trust and support that will enable them to begin and then remain on treatment.

Engage With Education
Once we know where we stand, both sides of the treatment equation can meet the inevitable challenges together. It is this partnership between provider and patient that creates the foundation of a successful treatment team, especially when those patients are PWID. Once patients have taken the first step to reach out, it is incumbent upon providers to identify and address their needs in order to keep them coming back.

In my experience, developing a program that successfully treats PWID begins with early and ongoing education of providers and staff across the spectrum of specialties. Although the number of studies is limited, the data they present argue in favor of treating PWID for hepatitis C. A recent systematic analysis revealed that PWID—even those who actively use drugs during treatment—have demonstrated acceptable sustained virologic response (SVR) rates of 37% for genotype 1/4 and 67% for genotype 2/3 after peg-IFN/RBV treatment for chronic HCV infection. Another analysis of pooled data found that PWID experience low reinfection rates (1% to 5% per year) following successful treatment. Additional pooled study results have found that PWID demonstrate 80/80/80 adherence rates of 82% (95% CI: 74% to 89%) and discontinuation rates of 22% (95% CI: 16% to 27%), both rates that approximate those for people who do not use drugs. Finally, the Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) study demonstrated that a multidisciplinary team integrating nursing and specialist support into existing community health clinics and opioid substitution treatment centers can successfully assess and engage PWID in HCV treatment. We have promoted these data as widely as possible to bring attention to the possibility of treating PWID successfully. Ongoing initiatives will evaluate strategies to improve HCV treatment uptake among PWID and enhance treatment outcomes, particularly in the context of new direct-acting antiviral (DAA) regimens.

To enhance hepatitis C treatment and care for PWID, there is a need to expand points of assessment. One provider group we should aggressively recruit is addiction specialists. Using their access to and intimate knowledge of these patients enables us to reach these patients on a more personal and immediate level. Reaching this group of providers is especially important when we recognize that many PWID are reluctant to engage in care at large, tertiary care centers. They are often more easily engaged at smaller community clinics and methadone treatment centers. Once engaged in an environment they are comfortable in and by providers they are familiar with, PWID could be either treated within drug and alcohol or community-based settings or referred to more specialized providers at larger secondary or tertiary care centers. The advent of IFN-free all-oral DAA regimens should enhance feasibility of hepatitis C treatment delivery within a broader range of settings.

By reaching out to specialists other than the “usual suspects” of hepatologists and gastroenterologists, we are following the very successful HIV care model. This outreach allows us to create care partners who recognize the real possibility of treating PWID successfully, if not by the individual provider, then by a readily available specialist. Furthermore, in keeping with the HIV model, a multidisciplinary team will enable us to maximize the possibility of successfully treating not only their hepatitis C, but also their common comorbid psychiatric difficulties, social isolation, and other medical issues.

Impacting Care and Treatment
We can affect both the health of our community and PWID by recognizing that they can be treated successfully with careful patient selection. Getting information into the hands of providers who may be more familiar with and trusted by PWID is an important first step. PWID should not be dismissed as “untreatable” but receive individualized assessment for treatment as undertaken for other patients with hepatitis C. A range of disease-based, social, and family factors require evaluation in relation to treatment readiness and potential impact on outcomes.

Rightfully, society at-large has concerns about the enormous expense associated with hepatitis C therapy and the potential for transmitted resistance due to suboptimal adherence in any patient with hepatitis C including PWID. Individualized hepatitis C treatment assessment thus provides the opportunity to optimize uptake and outcomes.

Educate yourself, educate others, and make a positive impact in everyone.

Recently published international recommendations from the International Network on Hepatitis in Substance Users, of which I am a co-author, supplement existing guidelines and address many issues associated with successfully treating HCV in PWID.

Your Thoughts?
I am interested in hearing your thoughts on treating HCV in PWID. Is there an outreach program in your community to engage these patients? What has your experience been in treating PWID for any medical condition? How have you overcome obstacles to treatment in this patient population?

Topics: HCV – Treatment

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