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 “Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial.” Talal AH, Markatou M, Liu A, Perumalswami PV, Dinani AM, Tobin JN, Brown LS. Journal of the American Medical Association 2024; 331(16):1369—1378. PMID 38568601
What question(s) does this study address?
The number of persons who inject drugs (PWID) in the United States has increased in the past decade, in large part due to the evolving opioid crisis. Recent estimates suggest that nearly 3.7 million people injected drugs in 2018. This trend has resulted in increases in Hepatitis C virus infections —as a consequence of using non-sterile injection equipment. In their most recent surveillance report, the Centers for Disease Control and Prevention (CDC) reported some 4,800 cases of acute Hepatitis C in 2022; among cases with risk information, the most commonly reported risk was injection drug use.
The current administration’s proposal for a National Hepatitis C Elimination Program identifies “substance use disorder treatment clinics” among the sites where rapid diagnosis of HCV infection and prompt initiation of curative treatment could substantially advance efforts to eliminate Hepatitis C. While opioid treatment programs (OTP) may seem obvious sites for HCV screening and treatment efforts, on-site HCV testing may not be available to all clients who enter these programs. Consider that a recent assessment of 11 state Medicaid programs found that among some 360,000 persons who initiated treatment for opioid use disorder, nearly three-quarters weren’t tested for HCV. And even in OTPs where clients receive HCV testing, other barriers can interfere with the initiation and successful completion of HCV treatment. Chief among these are the challenges associated with linking clients to off-site HCV treatment providers. Talal and his colleagues designed a clinical trial to compare treatment outcomes among OTP clients who received HCV treatment via referral to an off-site hepatitis specialist (i.e., usual standard of care) to those who received HCV treatment that was integrated into OTP services, via facilitated telemedicine.
What are the major findings of this report/article?
- 602 HCV seropositive participants were recruited from twelve OTPs in New York state. 312 (52%) were randomized to receive HCV treatment through referral to an off-site provider and 290 (48%) were randomized to receive HCV treatment that was integrated into OTP treatment via facilitated telemedicine.
- 61% of the participants were male, 51% were white, and 49% were racial/ethnic minorities. The mean age in the referral group was 49 years and 47 years in the telemedicine group.
- Clients receiving HCV care that was integrated into their opioid treatment had an initial on-site telemedicine encounter (facilitated by on-site case managers), blood draw, and evaluation by the telemedicine clinician. Subsequently, the clinician ordered DAAs (direct acting antiviral agents) electronically that were delivered monthly to the OTP sites and dispensed to participants along with their methadone. OTP staff dispensed take home DAA doses so participants could self-medicate on days when they did not visit the OTP.
- In both groups (referral and integrated HCV care) HCV RNA levels were measured at treatment completion and at weeks 4 and 12, posttreatment.
- 92% (268 of 290) in the integrated telemedicine group initiated HCV treatment compared to 40% (126 of 312) in the referral group.
- 85% of participants (246 of 290) in the OTP-integrated telemedicine group were cured of their HCV (i.e., achieved a sustained virologic response or SVR) compared to 34% (106 of 312) of those in the referral group.
- Minimal reinfections occurred. The incidence of HCV reinfection was 2.5 per 100 person years, with no significant differences between the two groups.
What are the implications for the prevention and control of viral hepatitis?
- Although co-location of HCV diagnostic and treatment services into harm reduction and substance use treatment programs is considered optimal, many real-world challenges make this goal difficult to achieve. Talal and his colleagues have demonstrated that integrating HCV care into OTPs via telemedicine can achieve HCV cure rates that are far superior to current, standard methods of referral to off-site HCV care.
- Telemedicine models of HCV care may also benefit PWID who are not currently enrolled in opioid treatment programs. Eighty-nine of 171 clients surveyed at a syringe service program (SSP) in Denver, Colorado reported current or past HCV infection. Eighty-eight percent of HCV positive clients reported that they would be “more likely” to get HCV treatment if they were able to do so at the SSP. Although in-person appointments were preferred, 77% of respondents were comfortable with receiving HCV care via a video appointment.
- Using telemedicine and other innovative models of care to expand access to HCV diagnosis and treatment for PWID will prevent disease progression and death. Recent analyses suggest that broad access to HCV treatment among PWID can reduce the incidence of new HCV infections at a population level, thus supporting HCV elimination goals.
