HCV Cure Rate Quadruples With Peer-Assisted Telehealth

Pills can cure infection with the hepatitis C virus (HCV), but getting the medication to patients who need treatment can be a challenge.

Many patients with HCV use drugs such as methamphetamine or heroin and were exposed to the virus by sharing needles. Lack of housing, difficulty getting to appointments, and mistrust of the healthcare system are potential barriers to care.

A new approach to treating HCV relies on trained peers who have used nonprescribed drugs themselves helping to arrange telemedicine visits and ensure patients receive direct-acting antiviral (DAA) therapy.

This strategy could multiply the number of patients with HCV who get treated and cured, recently published research showed.

Investigators conducted a trial of this strategy in rural Oregon with 203 participants with HCV. Most reported having used methamphetamine, fentanyl, or heroin and recently had experienced houselessness. About half of the participants randomly were assigned to receive peer-assisted telehealth; the others were referred by peers to local medical care.

Those assigned to telehealth were 6.7 times more likely to initiate treatment and 4.1 times more likely to have viral clearance 12 weeks after their last planned dose of a DAA, the researchers reported recently in Clinical Infectious Diseases.

The essence of the intervention is “meeting people where they are” and making it easy to access treatment, said Andrew Seaman, MD, with Oregon Health & Science University (OHSU), in Portland, Oregon, and Better Life Partners, an opioid use disorder treatment program, in Vermont, who led the study.

More Than a Liver Disease

HCV affects more than 2 million people and contributes to approximately 14,000 deaths each year in the United States, according to estimates from the US Centers for Disease Control and Prevention. Curing the infection has many physical, psychological, and societal benefits, Seaman said.

For one, HCV causes fatigue in many people, he said. The infection also is associated with an increased risk for diabetes, autoimmune disease, unstable mental illness, liver disease, and cancers of the liver and other organs.

Many people with HCV were exposed to the virus because they injected drugs during a vulnerable time, such as when they needed to share equipment to stop feeling sick, were using drugs compulsively, or had an abusive partner and could not access safe supplies, Seaman said.

“When you cure someone of hepatitis C, you are removing this constant internal reminder of these events in their lives,” he said. People who have been cured of HCV may have better relationships. They also may be more likely to use drugs more safely or to engage in substance use disorder treatment.

Once cured, patients cannot transmit the virus to someone else.

A Novel Approach

Although programs have involved peers in the care of patients with HCV for more than a decade, the paper showed a “novel way in which peers can provide support by facilitating telemedicine,” wrote Matthew Akiyama, MD, with Albert Einstein College of Medicine, in New York City, and colleagues in an editorial accompanying the journal article. Having peers assist with virtual visits “may allow people who use drugs to feel safer than in one-on-one encounters with clinicians due to high levels of mistrust for healthcare providers and the healthcare system,” they wrote.

Seaman agreed peers are “profoundly important to the intervention.” They can gain trust quickly where healthcare workers might tend to struggle. “Peers have a PhD in what it’s like to live in the body of someone who uses drugs in this country and especially in that community itself,” he said.

Pull Quote: ‘Peers have a PhD in what it’s like to live in the body of someone who uses drugs in this country and especially in that community itself.’

Meanwhile, telemedicine can overcome geographic and logistical constraints. In the trial, peers facilitated virtual visits by bringing phones or tablets to participants where they were. A participant could smoke a cigarette while talking to Seaman about their HCV.

“And we send them their medications and they get cured,” he said. “Obviously there’s more to it than that.” But streamlining the process from diagnosis to treatment may be key to getting patients treated, he said.

Completing the Workup

To enroll in the study, participants in both groups had peers help them get tested for HCV, which requires blood draws. For participants with damaged veins or without a car to get to the lab, completing this step without peer support can be a challenge, Seaman said.

Once testing confirmed an HCV infection, participants were assigned to receive telehealth or connected with another group of peers to facilitate treatment through the usual local program.

In the telehealth group, peers connected participants with clinicians at OHSU who prescribed one of two DAA regimens: Glecaprevir/pibrentasvir or sofosbuvir/velpatasvir. Peers then followed up with participants to see if they were taking the drugs or having any issues getting their prescriptions. Treatment lasted 8 or 12 weeks. About 3 months after their last pill, peers helped participants get to a lab to confirm whether they had detectable HCV ribonucleic acid.

The researchers found participants in the telehealth group were more likely to receive treatment (85% vs 12%; P P

Replicating this sort of intervention outside of rural Oregon is possible, Seaman said. Although results might vary from place to place, particularly in locations with relatively easier access to care, the study showed how effective this intervention can be at eliminating HCV, he said.

Considering the results of the trial and work by other groups, the editorialists called for scaling up programs that incorporate peers and telemedicine. “Ultimately, peer navigation and telemedicine are critical to HCV elimination,” they wrote, “because, in different ways, they meet people where they are.”

This trial was supported by the National Institute on Drug Abuse. Seaman had received investigator-initiated research funding from Merck, AbbVie Pharmaceuticals, and the Gilead Focus Foundation. Akiyama was supported by grants from the National Institutes of Health and had received research funding from Gilead Sciences and AbbVie.