Addiction clinics need physician education, lifted restrictions to treat HCV
Opioid agonist therapy clinics represent an important conduit for people who inject drugs to receive information, screening and treatment for hepatitis C. Within these clinics, however, physicians and addiction specialists self-reported low competence regarding current HCV treatments. Additionally, policies that restrict treatment for current and recent drug users present an ongoing barrier.
“From a public health perspective, when you treat patients who are actively using, this is the population you need to treat if you want to achieve the WHO goals of elimination by 2030,” Alain H. Litwin, MD, professor of medicine and psychiatry at Albert Einstein College of Medicine, told Healio.com/Hepatology. “By treating people who are actively using, you can reduce the community viral load. For new patients who are uninfected or those who have been treated successfully, they will be less likely to be infected or reinfected. If you don’t treat the active users, we will never achieve the goal of elimination.”
Physician, specialist education
Litwin discussed the results of the C-SCOPE study, presented this year at the International Symposium on Hepatitis Care in Substance Users. The aim of the study was to evaluate the competency of HCV testing, management and treating among physicians practicing in clinics that offer opioid agonist therapy.
Overall, 203 physicians replied to the C-SCOPE survey from the U.S. (n = 82), Europe (n = 92) and Australia and Canada (n = 29). The physicians included psychiatrists (29%), primary care or internal medicine physicians (26%), addiction medicine specialists (21%), addiction psychiatrists (20%), or other specialist (4%).
Most of the physicians saw testing (82%) and treatment (84%) as important for PWIDs. However, many physicians reported below average competency regarding treating and managing HCV (40%), knowledge of new treatments (37%), advising patients about new treatments (28%), interpretation of HCV test results (14%) and regular screening methods (12%).
“The majority of the physicians treating these patients are either psychiatrists or physicians specializing in addiction medicine,” Martine Drolet, global medical director at Merck, told Healio.com/Hepatology. “They do recognize the importance of screening and treating them, but they need support, they need education when it comes to recognizing treatments for their patients, when it comes to their own knowledge, and when it comes to even treating these patients.”
After a multivariate analysis, significant factors associated with below average self-reported competence to advise patients about new HCV therapies included being a psychiatrist vs. general practitioner or internist (adjusted OR = 4.34; 95% CI, 1.55-12.11) and fewer years of experience (aOR = 1.07; 95% CI, 1.02-1.13).
Similarly, being a psychiatrist (aOR = 5.75; 95% CI, 2.22-14.88) or an addiction medicine physician (aOR = 2.84; 95% CI, 1.18-6.86) vs. general practitioner or internist was correlated with below average self-reported competence to treat or manage HCV.
“Strong acknowledgement of the need to screen and treat is there, but the need for education ... this is something that Merck is committed to,” Drolet said, “to make sure that we increase the rate of treatment for [PWIDs], and moreover that we provide the tools for physicians who are caring for them to make sure we increase the rate of treatment for these patients.”
Restrictions, despite adherence
Litwin also presented results of the PREVAIL study at the International Symposium on Hepatitis Care in Substance Users. The study comprised 150 PWIDs with HCV genotype 1 who researchers randomly assigned to one of three innovative models of on-site care to determine rates of adherence, treatment completion and sustained virologic response.
Adherence was high in all three models: individual, self-administered treatment (74.4%); group treatment with peer mentoring (77.5%); and directly-observed treatment that paired HCV therapy at the same time as methadone or buprenorphine distribution (82.8%). Most patients in the individual (96.1%), group (95.8%) and directly-observed (98%) models completed treatment and most in the individual (96.1%), group (93.8%) and directly-observed (98%) models achieved sustained virologic response.
Additionally, the researchers observed no association between drug use within 6 months of HCV treatment, drug use at baseline or drug use during treatment and adherence or SVR.
“This adds further support to the idea that we should be treating these patients and that payers should be changing their restrictions,” Litwin said. “It’s really important because, in the United States, 71% of states have some restriction for [PWIDs]. Often, that’s based on nonevidence-based criteria such as duration of abstinence ... and many payers require urine toxicologies, which are not evidence based. As we showed in the study, it doesn’t predict anything.” – by Talitha Bennett
Grebely J. Self-Reported Competency Related to Testing, Management and Treatment of HCV Infection Among Physicians Prescribing Opioid Agonist Therapy: The C-SCOPE Study. Presented at: International Symposium on Hepatitis Care in Substance Users; Sept. 6-8, 2017; New York.
Litwin AH. The PREVAIL Study: Intensive Models of HCV Care for People Who Inject Drugs. Presented at: International Symposium on Hepatitis Care in Substance Users; Sept. 6-8, 2017; New York.
Disclosure: Litwin reports he received research grants from and is on the advisory board for Gilead Sciences and Merck Pharmaceuticals. Drolet is an employee of Merck.