Changes in risk behaviours during and following treatment for hepatitis C virus infection among people who inject drugs: The ACTIVATE study
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.
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Study participants
From May 11 2012, to September 30 2014, participants were enrolled at 17 sites in Australia (n = 5), Canada (n = 3), Switzerland (n = 3), Belgium (n = 2), Germany (n = 1), Norway (n = 2), and the United Kingdom (n = 1). Study recruitment was conducted through a network of hospital clinics (n = 9), drug and alcohol clinics (n = 3), office-based practices (n = 2) and community clinics (n = 3). Harm reduction services (i.e. OST and needle and syringe provision) were available for participants across all study sites.
Characteristics of study participants
Characteristics at enrolment for the 93 participants enrolled are shown in Table 1. The median age was 41 years (IQR 35–50 years), 83% were male, 69% had high school or higher education, 15% had part- or full-time employment and 76% had stable housing. Among 93 participants, 55 (59%) had injected in the past month prior to enrolment, and among those, 27% reported ≥daily injecting, 13% had used non-sterile needles and 15% had shared injection paraphernalia. Eighty-seven percent of participants
Discussion
This international multicentre study evaluated changes in risk behaviours longitudinally during and following HCV treatment among PWID with ongoing injecting drug use or receiving OST. Any injecting drug use and hazardous alcohol use decreased significantly throughout treatment and follow-up, whereas ≥daily injecting, use of non-sterile needles, sharing of injecting paraphernalia, and non-injecting drug use remained stable. OST increased during treatment, but this change did not endure towards
Funding
The ACTIVATE study was supported in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp. The Opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. The Kirby Institute is funded by the Australian Government Department of Health. The views expressed in this publication do not necessarily represent the position of the Australian Government. Håvard Midgard is supported by
Conflicts of interest
HM: Consultant/advisor for Gilead Sciences and Abbvie; sponsored lectures for Roche, Medivir, Gilead Sciences, Merck Sharp & Dohme and AbbVie. BC: Consultant/advisor and research grants from AbbVie, Cepheid, Gilead and Merck Sharp & Dohme. PB: Consultant/advisor and research grants from Abbvie, Bristol Myers Squibb, Gilead, Janssen and Merck. GRF: consultant/advisor and research grants from Abbvie, Bristol Myers Squibb, Gilead Sciences, Janssen, Roche and Merck/MSD. GR: Research grants from
Acknowledgements
The authors would like to thank the study participants for their contribution to the research, as well as current and past researchers and staff. They would like to acknowledge members of the study group:
Protocol Steering Committee—Gregory Dore (Chair, UNSW Sydney), Jason Grebely (UNSW Sydney), Philip Bruggmann (Arud Centres for Addiction Medicine, Zurich, Switzerland), Philippa Marks (UNSW Sydney), Brian Conway (Vancouver Infectious Diseases Center, Vancouver, Canada), Geert Robaeys
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2019, International Journal of Drug PolicyCitation Excerpt :One study reported a significant decrease in injecting equipment sharing, including mixing container, filter and water, during treatment and 24 weeks follow up (aOR 0.85, 95% CI 0.74- 0.99, n = 124), with a reduction in the number of participants reporting sharing from 54% at baseline to 17% at follow up (Alavi et al., 2015). In contrast Midgard et al. (2017) reported no association between treatment and injecting equipment sharing, including spoons, mixing containers, drug solution, water and filter, during treatment and 12 week follow up (OR 0.87, 95% CI 0.70–1.07, n = 93). One study investigating the impact of DAA based treatment on behavioural outcomes reported a significant reduction in the number of participants reporting needle and syringe sharing during treatment and 2 year follow up (OR 0.87, 95% CI 0.80- 0.94, n = 190) (Artenie et al., 2019).