CommentaryThe promise of treatment as prevention for hepatitis C: Meeting the needs of people who inject drugs?
Section snippets
The promise of treatment as prevention for HCV
We are in the midst of a changing HCV treatment landscape. Oral direct-acting antivirals (DAAs) have cured up to 100% of clinical trial participants from HCV, fuelling considerable optimism in the sector (Afdhal et al., 2014, Sulkowski et al., 2014). References to HCV eradication and elimination are now commonplace (Grebely and Dore, 2014, Ryder and Dillon, 2014). One key strategy in the HCV elimination toolbox is TasP. HCV TasP involves prioritisation and scale up of HCV treatment provision to
The limits of a population-based approach
TasP for HCV, as with HIV, has implications for clinical treatment decision-making and for the way health systems prioritise and target treatment provision. This has become a particularly fraught issue since the development and licencing of expensive DAAs. In the context of potential cost-justified rationing of DAAs in the UK, Innes, Goldberg, Dillon, and Hutchinson (2014) project that the prioritisation of treatment for PWID will optimally impact on transmission incidence (a TasP approach),
Needs of PWID in future HCV care
High HCV treatment interest and willingness has been evidenced among PWID, even in a context of interferon-based therapy provision (Canfield et al., 2010, Doab et al., 2005). International clinical guidelines increasingly recommend treatment assessment and access for people who are currently injecting (European Association for the Study of the Liver, 2014). Yet HCV treatment access and uptake is suboptimal worldwide – especailly for PWID (Martin, Vickerman, et al., 2013). Barriers to treatment
What can we learn from HIV?
The HIV field illustrates the multiple social structural barriers to ART treatment uptake and adherence for PWID (Milloy et al., 2012). There has been a dearth of prospective studies addressing the efficacy of TasP for PWID, despite findings by Wood et al. (2009) that community viral load, over and above condomless sex or syringe sharing, is predictive of HIV incidence. HIV TasP for PWID at best remains a concept – with ART access and uptake among this population woefully inadequate, at only 4%
Conclusion
It is well evidenced that PWID are interested in HCV treatment and have comparable adherence and SVR rates to other groups. Clinical guidelines are increasingly recommending HCV treatment assessment and access for PWID, yet provider reluctance to refer and treat is common. DAAs have revolutionised HCV treatment options, however these more efficacious drugs are unlikely to be available for all. In this context HCV TasP has the potential to be a powerful advocacy tool. Modelling work has
Conflict of interest
The authors have no conflicts of interest to declare.
Acknowledgements
Thank you to Jude Byrne, AIVL, for your input into ongoing TasP discussions. Thank you also to the three anonymous reviewers for your encouraging and helpful suggestions. This article builds on a brief discussion piece published in Lazarus et al., 2014 and draws on qualitative data from the NIHR funded Hepatitis C Treatment Journey Study. Magdalena Harris is funded by an National Institute of Health Research postdoctoral fellowship [NIHR-PDF-2011-04-031].
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