The HCV Care Cascade Among People Who Inject Drugs In A Norwegian Low-Threshold Setting: The Major Barrier Is Fibrosis Restrictions

Author: Midgard H, Ulstein K, Backe Ø, Vennesland K, Wüsthoff L, Dalgard O

Theme: Epidemiology & Public Health Research Year: 2017

Introduction: Improving hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWID) is fundamental to realize the benefits of direct-acting antiviral (DAA) treatment for this group. The aim of this study was to describe the HCV care cascade in a population of marginalized PWID attending a low-threshold clinic.

Methods: A primary care-based low-threshold HCV clinic was established in downtown Oslo in 2013 as an effort to reach a highly marginalised PWID population with ongoing injecting drug use. The clinic is located within the premises of the city’s harm reduction services, and is staffed by a general practitioner and two nurses with supported from an infectious diseases specialist. The model of care is characterised by flexible staff, ambulant work and broad use of existing networks within relevant low-threshold services and institutions. The nurses draw blood and operate a mobile transient elastography (TE) device, enabling complete integrated HCV diagnostics and treatment. Until March 2017, DAA treatment in Norway has been restricted to individuals with liver stiffness measurements (LSM) >7 kPa.

Results: By February 2017, the clinic had tested 392 individuals, of whom 253 (65%) had chronic HCV infection. 217 of 253 (86%) HCV RNA positive individuals were subsequently assessed with TE, and of those, 101 (47%) had LSM >7 kPa. Of 101 treatment eligible patients according to Norwegian guidelines, 85 (84%) had initiated DAA treatment. Three patients had lost contact with the clinic. Overall treatment uptake was 34% (85 of 253).

Conclusion: Despite high linkage to care, overall treatment uptake remained relatively low largely due to national fibrosis restrictions. From March 2017, unrestricted treatment for HCV genotype 1 infection was commenced in Norway. It remains to be seen how this will influence the care cascade.