Rapid on-site testing for hepatitis C virus (HCV) at a supervised injection site in Canada increases engagement and connection to care among people who inject drugs and improves access, according to findings published in The Lancet Regional Health Treatment Possibilities: Americas. Of those treated, 86% were cured.
Although hepatitis C is common among people who inject drugs, accessing care can be difficult, with barriers ranging from stigma to misinformation. While more than 95% of patients treated with direct-acting antiviral drugs are cured, many never receive the treatment they need.
Jeff Powis, MD, of Michael Garron Hospital in Toronto, and colleagues evaluated the availability of rapid point-of-care HCV RNA testing and linkage to caregivers using supervised injection sites at community health centres. Supervised consumption facilities enable people to use drugs in clean, safe spaces under the supervision of trained staff and provide primary health care and social services. The researchers also assessed the prevalence of hepatitis C and receipt of treatment.
This observational study was conducted between August 2018 and September 2021 and recruited 124 participants. The average age is 41 years, and 65% are male. More than half (57%) are white, 33% are Aboriginal and 10% are classified as “racialized non-Indigenous”. Nearly three-quarters are homeless or in unstable marriages, and 86 percent rely on social assistance as their primary income. Half said they inject fentanyl most often, and 68 percent said they inject it daily. Most people (76%) use safe injection sites daily, weekly, or several times a month.
Before the study, 69% of participants said they had been tested for hepatitis C, but 53% were unaware of their status. At the start of the study, 54 participants (44%) tested positive for HCV RNA, indicating a current active infection. Of those who tested positive, 72% were being diagnosed for the first time or were previously unaware of their positive status. Those who test negative are asked to repeat the test every three months.
The prevalence of hepatitis C was twice as high among people with unstable housing as among those in stable marriages, and the prevalence of hepatitis C among people who inject drugs daily was three times as high as among those who inject drugs infrequently.
Of the 70 participants who were HCV RNA negative at baseline, 37 returned for follow-up testing. During the follow-up period, 10 people were newly diagnosed with hepatitis C, and the cumulative incidence of hepatitis C at 15 months was 38%, or 35.1 cases per 100 person-years. Participants with recent HCV infection were on average younger and more likely to report daily injections than HCV-negative participants.
Of the 64 individuals who tested positive at baseline or during follow-up, 43 (67%) were referred to on-site health clinics for hepatitis C care. The median time between first positive HCV RNA test and receipt of care was 63 days. Newly diagnosed individuals were more likely to receive care than those who tested positive for HCV RNA at baseline.
Of the 43 people requiring care, 29 (67%) started treatment at a health center. Three others cleared the virus spontaneously without treatment. The median time between first positive HCV RNA test and initiation of treatment was 265 days. Older people, people who have been injecting drugs for a longer period of time, and people of Aboriginal or ethnic origin are more likely to start hepatitis C treatment. People who most often inject fentanyl are less likely to start treatment than people who most often inject heroin or prescription opioids.
Of the 29 people who started treatment, 25 achieved sustained virological response (SVR), a cure rate of 86%. Three were missing posttreatment SVR assessment. One person who initially did not achieve SVR subsequently retired and was cured at the end of the study period. There were 10 deaths during the follow-up period, 7 of which were due to overdose.
“We demonstrate that providing rapid, low-threshold point-of-care HCV RNA testing in a small-scale supervised consumption service allows us to diagnose HCV in high-prevalence populations and connect the most people to HCV care and treatment,” he researchers wrote. “By providing point-of-care HCV RNA testing in places where drug users go, our model successfully expands the reach of HCV RNA testing to highly marginalized groups at high risk for HCV infection.”
Click here to read the study in The Lancet Regional Health: Americas.
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