Hepatitis C virus (HCV) - infected people who use drugs (PWUD) with cirrhosis: need for urgent treatment of HCV infection to prevent liver-related complications

Background: People who use drugs (PWUD) make up the largest proportion of incident and prevalent Hepatitis C virus (HCV) infections in Canada. These individuals have often become infected with HCV remotely, and remain undiagnosed or untreated, with a risk of end-stage liver disease and/or hepatocellular carcinoma (HCC) in up to 25% of those with chronic infection. Treatment of HCV can reduce incidence of HCC by as much as 71%, even in individuals who already have cirrhosis. Thus, engaging HCV-positive PWUD in curative HCV care and maintaining long-term engagement of those with cirrhosis (for HCC screening) is an important part of long-term treatment, along with addiction care.

Methods: We conducted a retrospective chart review of all HCV-positive PWUD who have received direct-acting antiviral therapy at our centre, focusing specifically on those who were diagnosed with cirrhosis prior to treatment by transient elastography (FibroScan, or FS, >12.5 kPa) prior to treatment initiation. All individuals engaged at our centre have access to an integrated, multidisciplinary model of care to address their medical, social, psychological, and addictions-related needs.

Results: Since 2014, 348 eligible individuals have been initiated treatment at our centre, of whom 62 (18%) had cirrhosis at baseline. Demographic characteristics of those with cirrhosis include: mean age 59 years, 22% female, 22% HIV co-infected, 74% on opioid substitution therapy, 6% homeless or unstably housed, 25% with a diagnosed psychiatric issue, 23% engaged through community outreach programming. Of those on treatment, 55/60 (92%) have achieved sustained virologic response (SVR12, or cure of HCV infection), with 1 virologic relapse, and 4 individuals being lost to follow up. 2 individuals have completed treatment but are awaiting SVR bloodwork. Mean pre-treatment FS was 22.9 kPa ± 11. Mean post-treatment FS for those with available scores (n = 39) was 16.2 kPa ± 13, with 22 (56%) of those having a score in the non-cirrhotic range. All individuals remain under long-term care to assess for HCC, as well as for re-infection for those with ongoing risk behaviours.

Conclusion: These data demonstrate additional support for the continued expansion and prioritization of PWUD for HCV treatment. A significant proportion of these individuals already have advanced liver disease and require urgent treatment. These individuals have high cure rates, associated with reversal of fibrosis. This is associated with an improvement in quality of life, and may also enhance the benefit of their addiction care.