Better integration of hepatitis C testing with opioid treatment programs and improved efforts to reduce stigma could reduce barriers for people hesitant to seek treatment.

Health systems need to improve the integration of hepatitis C testing into opioid treatment programsif Australia is to eradicate hepatitis C by 2030, according to a research letter published in the Medical Journal of Australia today.

Injecting drug use, including heroin use, is the main risk factor for hepatitis C infection in Australia.

Despite a surge in hepatitis C treatment in 2016 with the introduction oral antiviral therapies, treatment rates have since declined.

“We had a huge surge of early treatment because the new oral antiviral hepatitis C treatments were so much better than previous injectable treatment that came with a vast amount of side effects,” lead article author Dr Christopher Tremonti told InSight+.

Dr Tremonti is an addiction specialist and clinical pharmacologist with almost a decade of experience working with people with substance dependence.

Tackling treatment hesitancy in people with hepatitis C - Featured Image
Addiction specialist and clinical pharmacologist Dr Christoper Tremonti

“It was perfect for those patients aware of their hepatitis C infection waiting for a simpler treatment, and those already engaged with the medical system for other reasons, such as opioid treatment therapy, who could be easily detected,” Dr Tremonti said.

“But now we face the challenge of finding those with hepatitis C who are not engaged with the medical system, those who do not regard it is a priority for them, and those anxious about the new treatments because of past bad experiences.”

The Australian Treatment Outcome Study

The Australian Treatment Outcome Study (ATOS) is the largest and longest cohort study of people with heroin dependence in Australia, and has followed 615 people since 2001, with follow-up occurring six times throughout its duration.

For the latest follow-up, the research authors invited 130 participants to attend the Royal Prince Alfred Hospital in Sydney between 1 September 2019 and 31 April 2021.

Of the 130 invited participants, 99 people were found to have been exposed to hepatitis C (80%).

Twenty-five of those participants had active hepatitis, and none of them had sought treatment.

Within the following two years, 14 of the 25 participants (56%) had still not commenced treatment.

Tackling treatment hesitancy

The authors believe treatment hesitancy may be a factor in reduced treatment rates.

“Amongst a cohort of people with heroin dependence with high levels of hepatitis C exposure, there remains a small subset of patients with hesitancy towards treatment,” Dr Tremonti said. “This may limit our ability to completely eradicate hepatitis C.

“Treatment hesitancy isn’t just a patient problem, it’s a system problem.

“We can only engage people with the medical system if they trust it, and we do this by treating patients – especially those who may feel marginalised due to substance use – with dignity, listening empathetically and minimising stigma.”

Dr Tremonti explained that there are many factors that may make a person hesitant to engage with treatment.

“Patients may be hesitant because of a previous bad experience with older treatments, which had several nasty side effects, or the bad experiences of someone else close to them,” he said.

“Some people who inject drugs also report feeling stigmatised by health care providers, and so are distrustful of modern treatments.

“Furthermore, many [people] have competing financial or social interests and so don’t prioritise what is, in many cases, an asymptomatic infection, in spite of the potential long term harms hepatitis C may cause them.”

The role of opioid treatment programs

Dr Tremonti believes treatment-hesitant patients would benefit from hepatitis C treatment being better integrated with opioid treatment programs.

“Opioid treatment programs should be a one-stop shop for detection and treatment, and many already are,” he explained.

“Injecting drug use remains the number one risk factor for hepatitis C in Australia, and for many people who inject drugs, opioid treatment programs are the only point of contact with the medical system.”

Dr Tremonti explained that many people with hepatitis C do not have primary care physicians due to a lack of access, cost, or limited health literacy.

“Asking them to see another health care provider, such as a GP, for detection or treatment creates a barrier,” he said.

“Integrating detection and treatment into opioid treatment programs means we capture more people with hepatitis C and make it easier for them to get treatment.

“On top of that, re-infection remains relevant amongst those who continue to inject drugs, so integrating annual hepatitis C testing into opioid treatment programs minimises the chances of missing re-infection.”

The road to eradication

Dr Tremonti is realistic about the challenges of eradicating hepatitis C in Australia by 2030.

“By the numbers, Australia is tracking very well and it’s a credit to everyone involved so far,” he told InSight+.

“However, I think treating the final 5% of people with hepatitis C will be very challenging, and that may lead to re-infections in the community.

“I would suggest by 2030 we will have a situation similar to [human immunodeficiency virus (HIV)], where rates of new infection are very low, but we never quite reach full eradication.

“Nonetheless, that would be a huge step from where we’ve come from.”

Read the research letter in the Medical Journal of Australia.

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