Download Update on Blood Borne Viral Infections

Management of Hepatitis C in the Community – one
man’s journey!!!
Dr. Shay Keating
The National Drug Treatment Centre
Who am I?
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A doctor
The Medical Officer in the National Drug
Treatment Centre (NDTC)
Associate Specialist in Sexual Health and HIV – St.
James’s hospital
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But mostly – I’m the ‘who the *?#@ is he?’
My journey in HCV care
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It began in 1990s in the addiction services – the then ERHA –
now the HSE
Very little focus on hepatitis C
Poor knowledge among the service users – ‘at least I don’t
have HIV’
Very poor information available
Management of HCV - What could we do in 1990s?
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Refer for specialist review
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Facilitate illicit drug and alcohol cessation
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Optimise social support
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Offer advise on minimising the risk of transmission to others
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Provide further virological testing where appropriate
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Immunise against hepatitis A and B
IVDU – Irish context (approximates)
IVDU in Dublin
~14000
70% HCV antibody positive
~10000
70% of those HCV RNA detected
~70000
50% genotype 1
50% ‘non 1’, mainly 3
Treating HCV Positive Drug Users in 1990s
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Many drug users were socially marginalised with poor access to healthcare
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Many were unaware of the dangers of HCV infection – this was improving
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Many too unstable – actively using illicit drugs or alcohol
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Non attendance at appointments was a significant problem in referral for
specialist hepatology/ID advice – hugely frustrating for hepatology/ID, for
primary care and addiction services
Adherence to treatment was often poor – SIDE EFFECTS!!!
Strategies to facilitate HCV treatment in IVDU
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Directly observed therapy (DOT)
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DOT in IVDU context refers to treatment delivery in same
location where they receive their opiate replacement therapy
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DOT has been shown to facilitate treatment adherence in IVDU
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Drug users might miss OPD appointments but will rarely miss
the drug treatment clinic and opiate substitute medication
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Used for TB treatment – Salomon et al., 1997
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Used for HAART in HIV/AIDS – Sorensen et al., 1998, Clarke et
al., 2000.
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General practice engagement in ‘shared care’ approach
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Development of HCV liaison nurse specialist positions
The National Drug Treatment Centre
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The Natonal Drug Treatment Centre (formerly the DTCB) is a
Specialised Addiction Centre in Dublin and the largest Drug
Treatment facility in Ireland
Currently approximately 550 attendees, 80% of whom are
HCV positive – many with psychiatric co-morbidities
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Of those not co-infected with HIV, 70% are HCV RNA positive
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Approximately 50% genotype 1 and 50% genotype 3
On-site HCV Treatment at the NDTC
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In 2003, I introduced a HCV treatment pilot study with DOT
into the NDTC
Rationale: ‘To treat the patients with hepatitis C in the
same location in which they receive their methadone
with a view to retaining the patients in treatment’
Regular medical review – Liaison with Professor Colm
Bergin, Infectious Diseases Consultant, St. James's Hospital
Regular psychiatric review
Pilot Study
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Not to show that the treatment works
But
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A proof of concept – that patient retention in
treatment can be improved if therapy is initiated
in a specialist drug treatment setting with
directly observed therapy and with appropriate
medical and psychiatric support on site.
On-site HCV Treatment ‘Pilot Study’
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Pilot study of nine patients – 6m/3f
All HCV RNA positive genotype ‘non 1’ mono-infected – HIV
and HBV negative
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8 were genotype 3, 1 was genotype 2
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Liver biopsies not performed
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Stable re. drugs/alcohol for minimum of 6 months
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Guaranteed contraception
Treatment endpoints
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Primary
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Efficacy of treatment – SVR 24 weeks post treatment cessation
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Retention in treatment
Secondary
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Management of medical and psychiatric complications on-site with
continued drug stability
On-site HCV Treatment ‘Pilot Study’
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HCV treatment initiated at NDTC
HCV treatment team – me!, a nurse, a psychiatric registra
and a counsellor
Peginterferon injection given weekly by the nurse and
ribavirin was dispensed weekly on site
Pilot Study Findings
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8 of 9 - finished programme (89% retention in
treatment)
8 of 9 had an SVR (efficacy is comparable to
hospital based setting)
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5 of 9 - haematological difficulties
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3 of 9 - significant depressive symptoms
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3 of 9 relapsed briefly into active addiction
Follow-up to pilot study
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In 2005, the programme was extended to
include HCV genotype 1
Pathway for liver biopsy established in St.
James's
Facilitated by I.D. Department/Prof Colm Bergin
and Radiology in St. James's hospital
Summary
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Hepatitis C is one of the treatment successes of modern medicine
Many patients have a good chance of a cure with the therapies
available today
Illicit drug use is still the commonest means of contracting HCV in
the developed world
Treatment delivery needs to take the subculture of illicit drug use
into consideration