Selected and summarized by Ronald O. Valdiserri, MD, MPH, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, and Co-Chair of HepVu.
Dr. Valdiserri reviews significant articles on prevention, public health, and policy advances in viral hepatitis. This month, he highlights “Mobile Telemedicine for Treating Chronic Hepatitis C among Rural People who Inject Drugs.”
What question(s) does this study address?
Persons who inject drugs (PWID) are at increased risk for Hepatitis C virus (HCV) infection as a consequence of using non-sterile injection equipment. Although injection drug use, and associated HCV infection, is not limited to a single region of the U.S., the burden of HCV infection among PWID is especially pronounced in rural areas of the United States. There are a number of reasons why this is so, including stigmatizing attitudes toward PWID, a lack of drug treatment and syringe service programs (SSPs), and inadequate HCV diagnostic and treatment resources.
Approaches to HCV care that incorporate telemedicine have been shown to increase cure rates among persons who use drugs. Friedmann and his colleagues sought to test whether a mobile telemedicine-based HCV treatment intervention for rural PWIDs would increase HCV treatment initiation and viral clearance and also result in decreased sharing of injection equipment. Their study involved 150 PWID recruited throughout April 21, 2022, to September 13, 2024, from rural areas in New Hampshire and Vermont using a mobile van parked in areas where PWID were known to congregate. All participants were aged 18 years or older, had a history of injection drug use, and untreated chronic HCV infection.
To test the hypothesis, participants were randomly assigned to either mobile telemedicine HCV care (MTC) or care navigation and facilitated referral to a local HCV provider (enhanced usual care, or EUC). The MTC group received their HCV care, including telemedicine visits, on the mobile van. All participants from each of the two groups had access to on-demand syringe services provided on the mobile van. Also, all participants received monetary compensation for their time spent on screening, lab testing, and study visits.
What are the major findings of this report/article?
- The researchers screened 503 PWID, found 169 to be eligible, and randomized 75 persons each to the MTC and the EUC groups. Nineteen (19) of the potentially eligible participants were lost to follow-up or declined to participate.
- The 150 study participants had a mean age of 38.1 years, 68.7% were male, and 89.3% were white. Drug injection in the last 30 days was reported by 64.7% of the participants and 70% had experienced homelessness in the previous 6 months. At baseline, sharing injection equipment was reported more frequently by the EUC group (37.3%) compared to the MTC group (26.7%).
- Losses to follow-up occurred in both treatment groups due to incarceration, death, or other reasons. In the MTC group 18 persons were lost to follow-up and 13 persons were lost to follow-up in the EUC group.
- Participants in the MTC group had higher rates of initiating HCV treatment (57.3%) compared to persons in the EUC group (26.7%).
- MTC participants also had higher rates of viral clearance at 12 weeks compared to EUC participants. 28 participants in the MTC group (37.3%) achieved viral clearance compared to 14 persons in the EUC group (18.7%).
- No significant differences were noted in the reported sharing of injection equipment across the two groups. Across all follow-up visits 35 participants in the MTC group (46.7%) reported sharing injection equipment compared to 37 in the EUC group (49.3%).
What are the implications for the prevention and control of viral hepatitis?
- Compared to enhanced usual care (i.e., HCV care navigation and facilitated referral by study staff to a local provider), mobile telemedicine care for HCV provided on a van resulted in increased initiation of HCV treatment and a doubling of viral clearance among rural PWIDs.
- These findings suggest that even with care navigation, facilitated referral to HCV providers is a “suboptimal” approach for curing HCV among rural PWIDs.
- Both groups had equal access to harm-reduction supplies from the van and persons in the MTC group did not report decreased sharing of drug injection equipment compared to persons in the EUC group.
- Another study of HCV treatment among rural PWIDs found that consistent peer contact was a better predictor of decreased equipment sharing rather than initiation of HCV treatment or HCV cure status. This finding suggests that peer-delivered harm reduction services must be an essential component of any program seeking to diagnose and cure HCV among PWIDs.
