Solving the hepatitis C epidemic among people with substance abuse disorders

As an editorial published online on April 25 in the Annals of Internal Medicine notes, this population typically does not have easy access to conventional health care so it is difficult to screen, diagnose and treat these individuals.

"People with substance use disorders can account for as much as 80 percent of infected individuals in developed countries, a direct result of the opioid epidemic in the U.S.," said Andrew H. Talal, MD, the lead author of the editorial and professor, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo.

Talal, a leading expert in liver disease, is a researcher with the Clinical and Translational Science Institute at the University at Buffalo, funded by a National Institutes of Health Clinical and Translational Science Award. He is currently principal investigator with other UB faculty on a $7 million Patient-Centered Outcomes Research Institute award dedicated to developing innovative ways to treat HCV in persons with substance use disorders. The award funds efforts with these patients throughout New York State, including New York City, Buffalo, Rochester, Syracuse and the Hudson Valley.

According to Talal, a combination of factors all work to prevent these patients from receiving the diagnoses and care they need. Such factors range from discomfort in conventional health care settings and lack of HCV-related knowledge to fear of stigmatization that can result from an HCV diagnosis. That's in addition to insurance barriers and physicians' general reluctance to treat this population.

According to the editorial, "New approaches for persons with substance use disorders are required at every step in the HCV care paradigm."

The reason is that following a decade of fairly steady declines in this population, there have been recent sharp increases in HCV.

"We're seeing infection hotspots," Talal said, noting that this is partly a result of the opioid epidemic, particularly where needle exchange programs, for example, are not available.

Such programs are key, Talal said, citing a report issued earlier this month by the National Academies that found that people who inject drugs account for approximately 75 percent of all new HCV infections.

To better reach persons with substance use disorders, the editorial states, HCV screening and linkage to care must improve. Screening can be especially problematic because it typically requires two steps: confirmation that the person has been exposed to HCV through an antibody test followed by additional blood work to determine if the infection is active. Currently, the second step must be conducted in a conventional laboratory, a setting these patients rarely access. Recent advances, however, are designed to assess whether all of required analyses could be done onsite.

Once a diagnosis is made, getting patients connected with providers is another major hurdle.

"At best, only 20 percent of these patients connect with a provider for treatment," Talal explained, "and often it's far less than that."

Talal and his colleagues at UB and other institutions and care facilities have been developing promising ways to better connect these patients with the care that they need by integrating HCV screening and treatment into methadone clinics that these patients already regularly attend and by reaching patients in the corrections system via telehealth techniques.