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Advocates Urge Consideration of Hepatitis C Treatment for Active Injection Drug Users

Advocates with the Treatment Action group (TAG) have successfully urged hepatology experts to change hepatitis C management guidelines to eliminate a recommendation that substance users should be abstinent from drugs or alcohol for 6 months before they are eligible for treatment.

Historically, many clinicians have hesitated to treated active injection drug users (IDUs) and other active substance users for hepatitis C virus (HCV) infection, due to concerns related to presumed inability to adhere to therapy, poor tolerance of interferon side effects such as depression, and high risk of reinfection due to continued needle-sharing.

Older hepatitis C treatment guidelines typically recommended that substance users should be abstinent for 6 months before being considered for anti-HCV treatment.

But a growing body of evidence indicates that IDUs -- including people on methadone who relapse into occasional use as well as individuals who continue regular active injection -- can achieve good treatment outcomes if they receive the support they need, especially in a multi-disciplinary setting that enables access to multiple services at a single site or with a single care team.

Current National Institutes of Health (NIH) consensus guidelines state that IDUs, especially those on methadone maintenance or similar opiate substitution therapy, should not be routinely denied hepatitis C treatment, but should be evaluated on an individual basis.

The American Association for the Study of Liver Diseases (AASLD) published updated practice guidelines for the diagnosis, management, and treatment of hepatitis C in the April 2009 issue of Hepatology.

Advocates with TAG discovered that the AASLD guidelines, still included the 6 month abstinence waiting period. After calling this discrepancy to the authors' attention, the hepatology experts indicated that they would change the guidelines to agree with the recommendations of the NIH consensus panel.

Below is an update from TAG describing the issue and the group's efforts.

TAG Collaboration Changes Updated
Hepatitis C Treatment Guidelines

In April 2009, the American Association for the Study of Liver Diseases (AASLD) published updated Hepatitis C Virus (HCV) Practice Guidelines. The Practice Guidelines are a useful and influential tool for busy clinicians, who are often unable to wade through tall stacks of research papers to discover the standard of care for diagnosis, management and treatment of HCV.

Hepatitis C is rampant among current and former injection drug users, since it is transmitted by direct blood-to-blood contact. Untreated hepatitis C leads to cirrhosis in 20-30% of cases. HCV treatment, when successful, can eradicate the virus and halt progression to cirrhosis, liver cancer and liver failure.

Unfortunately, HCV treatment is often withheld from current and former drug users, despite medical need, stability and willingness to undergo it, and NIH guidelines recommending HCV treatment decisions on a case-by-case basis since 2002. However, the field has continued to lean towards restricting, not broadening HCV treatment access, despite mounting evidence that current and former drug users can be safely and effectively treated.

Increasing quality of, and broadening access to HCV treatment has been a cornerstone of TAG's Hepatitis/HIV Project. TAG staffer Tracy Swan carefully monitors HCV treatment guidelines to this end. When she and a colleague, Jen Curry, from Harm Reduction Coalition, spotted an apparent contradiction in the recommendations for treatment of active drug users, they jumped into action.

The updated Practice Guidelines suggested that a minimum of six months of abstinence from drugs and alcohol should be a prerequisite for HCV treatment and consideration of treatment for active drug users as part of a multidisciplinary approach.

Swan and Curry wrote to the authors, asking that "...Practice Guidelines [become]... internally consistent in suggesting that clinicians broadly consider HCV treatment for active drug users in the context of supportive, multidisciplinary care." Their letter was published in July of 2009, along with a response from the authors. Swan, Curry and their colleagues are delighted to report that the Practice Guidelines will be amended accordingly.

8/14/09

Source

Treatment Action Group web site.