Changes in risk behaviours during and following treatment for hepatitis C virus infection among people who inject drugs: The ACTIVATE study

Abstract

Background

The risk of hepatitis C virus (HCV) reinfection due to continued injecting risk behaviours might remain a barrier to HCV treatment among people who inject drugs. We aimed to evaluate changes in risk behaviours during and following HCV treatment among people with ongoing injecting drug use or receiving opioid substitution treatment (OST).

Methods

ACTIVATE was an international multicentre clinical trial conducted between 2012 and 2014. Participants with HCV genotypes 2/3 infection were treated with peg-interferon/ribavirin for 12 or 24 weeks and completed a self-administered behavioural questionnaire at each study visit. The impact of time in treatment and follow-up on longitudinally measured recent (past month) behavioural outcomes was evaluated using generalized estimating equations.

Results

Among 93 enrolled participants (83% male, median age 41 years), 55 (59%) had injected in the past month. Any injecting drug use decreased during HCV treatment and follow-up (OR 0.89 per incremental study visit; 95% CI 0.83–0.95). No significant changes were found in ≥daily injecting (OR 0.98; 95% CI 0.89–1.07), use of non-sterile needles (OR 0.94; 95% CI 0.79–1.12), sharing of injecting paraphernalia (OR 0.87; 95% CI 0.70–1.07) or non-injecting drug use (OR 1.01; 95% CI 0.92–1.10). Hazardous alcohol use decreased throughout (OR 0.56; 95% CI 0.40–0.77) and OST increased between enrolment and end of treatment (OR 1.48; 95% CI 1.07–2.04).

Conclusions

Recent injecting drug use and hazardous alcohol use decreased, while OST increased during and following HCV treatment among participants with ongoing injecting drug use. These findings support further expansion of HCV care among PWID.

Introduction

The burden of hepatitis C virus (HCV) infection among people who inject drugs (PWID) is increasing, particularly among older individuals (Hajarizadeh, Grebely, & Dore, 2013; Kielland, Skaug, Amundsen, & Dalgard, 2013). Although HCV treatment in PWID has shown good outcomes (Aspinall et al., 2013; Hellard, Sacks-Davis, & Gold, 2009) and is recommended by international guidelines (AASLD-IDSA, 2015; EASL, 2017; Grebely et al., 2015; WHO, 2016), access to treatment has been limited (Alavi et al., 2014; Grebely et al., 2009; Iversen et al., 2014) due to multiple barriers to care (Bruggmann, 2012; McGowan & Fried, 2012). With increasing use of tolerable and highly effective interferon (IFN)-free directly acting antiviral (DAA) regimens, HCV treatment for PWID should become more feasible.

The potential risk of HCV reinfection due to continued injecting risk behaviours is of considerable interest as it might compromise both individual- and population-level treatment benefits among PWID (Midgard et al., 2016). Concern has also been raised that side effects of IFN-based treatment could mimic opioid withdrawal symptoms and hence promote injecting risk behaviours (Myles, Mugford, Zhao, Krahn, & Peizhong, 2011; Schaefer, Sarkar, & Diez-Quevedo, 2013). On the other hand, receiving HCV-related information and counselling through interaction with health care providers could enhance patient empowerment and lead to favourable behavioural change (Bruneau et al., 2014; MacArthur et al., 2014). A better understanding of patterns of drug use and risk behaviours, and the potential impact of HCV treatment, is needed as we enter the DAA treatment era.

There is, however, limited data on the relationship between HCV treatment and risk behaviours. Some earlier studies of HCV treatment among people receiving opioid substitution treatment (OST) have shown that drug use did not increase during treatment (Mauss, Berger, Goelz, Jacob, & Schmutz, 2004; Sasadeusz et al., 2011). In a study among PWID with recent HCV infection (Alavi et al., 2015), HCV treatment was not associated with increased injecting drug use during follow-up, but was associated with decreased sharing of ancillary injecting equipment. In a recent study of IFN-free HCV treatment for persons receiving OST (Dore et al., 2016), illicit drug use remained unchanged throughout treatment.

The ACTIVATE (A Collaborative Trial in Injectors of indiViduAlized Treatment for genotypE 2/3) study was designed to investigate IFN-based HCV treatment among people with ongoing injection drug use or receiving OST (Grebely et al., 2017). The primary aim of the present study was to evaluate changes in recent injecting drug use during and following HCV treatment among participants enrolled in the ACTIVATE study. The secondary aims were to assess changes in recent injecting risk behaviours, non-injecting drug use, hazardous alcohol use and OST.