Treating HCV in PWID: New prospects for managing an elusive population

People who inject drugs have historically represented a population at high risk for hepatitis C virus. However, these patients are often wary of authority figures or entities that might draw attention to or monitor their behavior. This caution may negatively affect their incentive to pursue treatment. The significant side effects of interferon-based therapies — previously the standard of care for HCV —may deter patients even more than fear of authority, as the side effects include IFN-induced bone marrow depression, flulike symptoms, neuropsychiatric disorders, and autoimmune syndromes. These regimens are also complicated and time-consuming, requiring 6 months of injections and a great deal of adherence.

“These treatments were very complicated, with a lot of nasty effects,” John F. Dillon, MD, professor of hepatology and gastroenterology at the School of Medicine, University of Dundee, Scotland, told Healio Gastroenterology and Liver Disease. “There were dangers and risks about taking it, and it required a lot of adherence and monitoring, a lot of rules and regulations, which made it difficult for these patients.”

The advent of more effective, more convenient drugs for HCV has opened new possibilities for engaging and effectively treating PWID, and controlling HCV’s transmission in this population. Dillon spoke with Healio Gastroenterology and Liver Disease about the changing landscape in treating PWID for HCV.

Question: The introduction of these new medicines could mean a big change in how HCV is treated in PWID. Have things begun to change already?

Answer: They have in some areas, but further change is still needed. There are two factors that might prevent patients from getting these medications and being cured. First, the new drugs are very expensive; this has caused some noise in the press. The list prices in the [United] States are very high, and they vary across different countries. So, these are new and expensive drugs, and there has been a degree of rationing of these drugs to those with most advanced disease, and so it can still be difficult for PWID to gain access to these therapies. PWID still die from liver cirrhosis and other problems associated with HCV.
experiment with drugs for a period, and then reintegrate back into what would be considered normal society. You have an opportunity to treat these patients while they’re in the injecting community, but once they finish injecting and recover and move back into conventional communities, they keep their past hidden because it’s stigmatized. So, unfortunately, you’ve missed the opportunity to treat these people, and many of them will present very late with cirrhosis and cancer. For this reason, there is pressure to find people who are infected with HCV early, and treat them.

Q: Has early treatment shown benefits in terms of curing more patients?

A: Treating them early has its advantages, but engaging this community can be difficult. The other thing that is changing the landscape here is the use of treatment as prevention.

Q: Are efforts being made to bring the costs of these drugs down, or to make early HCV treatment a bigger priority?

A: That’s certainly part of the debate. Most of the evidence for treating early comes from mathematical models and cost effectiveness analysis, rather than large scale real-world experiments that show it works.

Q: How are you reaching PWID for the study?

A: We’re approaching them through needle exchanges. In the U.K., PWIDs can get clean needles at the needle exchanges. At the needle exchanges that we visit, we know about 20% of the people there develop HCV per year. They don’t already have HCV, so they are clearly actively acquiring infection.

Q: How has the study been going so far?
A: The uptake into the study has been good; the study is still in progress, but the uptake has been good. That is the first part of the experiment — to show that we could engage people in treatment. And the cure rates in this population are as good as they are in the general population. But it’s too early to say whether it’s reducing transmissions.

Q: Do you think the fact that the new drugs are simpler and have fewer side effects will improve adherence among PWID?
A: I think as the drugs have become simplified and more effective, physicians are now seriously thinking about trying to deliver this treatment into this population, particularly among patients who are being prioritized for treatment, previously those with more advanced cirrhosis, are largely being treated now, or have been brought to treatment.

Q: Do you think at some point the priority will broaden so that treatment won’t be restricted to people with more advanced diseases in the PWID population?

A: I think that as people become convinced by the healthy economic argument, it will move that way. If the drugs are still costly, using these drugs to treat one person, and preventing six people from becoming infected, makes much more sense than waiting for six people to become infected and treating them later.
by Jennifer Byrne

For more information:

John Dillon, MD, can be reached at Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Level 5, Mailbox 12, Ninewells Hospital & Medical School, Dundee, DD1 9SY.

Disclosure: Dillon reports he has received honoraria for lectures and his institution has received research grants from Gilead, Roche, Janssen, Abbvie, MSD and BMS.

Editor's note: This article has been updated with Dillon's relevant financial disclosures.

People who inject drugs have historically represented a population at high risk for hepatitis C virus. However, these patients are often wary of authority figures or entities that might draw attention to or monitor their behavior. This caution may negatively affect their incentive to pursue treatment. The significant side effects of interferon-based therapies — previously the standard of care for HCV —may deter patients even more than fear of authority, as the side effects include IFN-induced bone marrow depression, flulike symptoms, neuropsychiatric disorders, and autoimmune syndromes. These regimens are also complicated and time-consuming, requiring 6 months of injections and a great deal of adherence.

“These treatments were very complicated, with a lot of nasty effects,” John F. Dillon, MD, professor of hepatology and gastroenterology at the School of Medicine, University of Dundee, Scotland, told Healio Gastroenterology and Liver Disease. “There were dangers and risks about taking it, and it required a lot of adherence and monitoring, a lot of rules and regulations, which made it difficult for these patients.”

The advent of more effective, more convenient drugs for HCV has opened new possibilities for engaging and effectively treating PWID, and controlling HCV’s transmission in this population. Dillon spoke with Healio Gastroenterology and Liver Disease about the changing landscape in treating PWID for HCV.

Question: The introduction of these new medicines could mean a big change in how HCV is treated in PWID. Have things begun to change already?

Answer: They have in some areas, but further change is still needed. There are two factors that might prevent patients from getting these medications and being cured. First, the new drugs are very expensive; this has caused some noise in the press. The list prices in the [United] States are very high, and they vary across different countries. So, these are new and expensive drugs, and there has been a degree of rationing of these drugs to those with most advanced disease, and so it can still be difficult for PWID to gain access to these therapies. PWID still die from liver cirrhosis and other problems associated with HCV.
experiment with drugs for a period, and then reintegrate back into what would be considered normal society. You have an opportunity to treat these patients while they’re in the injecting community, but once they finish injecting and recover and move back into conventional communities, they keep their past hidden because it’s stigmatized. So, unfortunately, you’ve missed the opportunity to treat these people, and many of them will present very late with cirrhosis and cancer. For this reason, there is pressure to find people who are infected with HCV early, and treat them.

Q: Has early treatment shown benefits in terms of curing more patients?

A: Treating them early has its advantages, but engaging this community can be difficult. The other thing that is changing the landscape here is the use of treatment as prevention.

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Q: Are efforts being made to bring the costs of these drugs down, or to make early HCV treatment a bigger priority?

A: That’s certainly part of the debate. Most of the evidence for treating early comes from mathematical models and cost effectiveness analysis, rather than large scale real-world experiments that show it works.

Q: How are you reaching PWID for the study?

A: We’re approaching them through needle exchanges. In the U.K., PWIDs can get clean needles at the needle exchanges. At the needle exchanges that we visit, we know about 20% of the people there develop HCV per year. They don’t already have HCV, so they are clearly actively acquiring infection.

Q: How has the study been going so far?
A: The uptake into the study has been good; the study is still in progress, but the uptake has been good. That is the first part of the experiment — to show that we could engage people in treatment. And the cure rates in this population are as good as they are in the general population. But it’s too early to say whether it’s reducing transmissions.

Q: Do you think the fact that the new drugs are simpler and have fewer side effects will improve adherence among PWID?
A: I think as the drugs have become simplified and more effective, physicians are now seriously thinking about trying to deliver this treatment into this population, particularly among patients who are being prioritized for treatment, previously those with more advanced cirrhosis, are largely being treated now, or have been brought to treatment.

Q: Do you think at some point the priority will broaden so that treatment won’t be restricted to people with more advanced diseases in the PWID population?

A: I think that as people become convinced by the healthy economic argument, it will move that way. If the drugs are still costly, using these drugs to treat one person, and preventing six people from becoming infected, makes much more sense than waiting for six people to become infected and treating them later.
by Jennifer Byrne

For more information:

John Dillon, MD, can be reached at Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Level 5, Mailbox 12, Ninewells Hospital & Medical School, Dundee, DD1 9SY.

Disclosure: Dillon reports he has received honoraria for lectures and his institution has received research grants from Gilead, Roche, Janssen, Abbvie, MSD and BMS.

Editor's note: This article has been updated with Dillon's relevant financial disclosures.