1 July 2005

Hep C in dependency patients: prevalence and outcomes

Hepatitis C virus prevalence and outcomes among injecting drug users on opioid replacement therapy. Hallinan R, Byrne A, Amin J, Dore GJ. J Gastro Hepatology 2005 20;7:1082-1086



Dear Colleagues,

This item from our own surgery shows that of 178 injectors on methadone/buprenorphine maintenance treatment, 75% tested positive for hepatitis C (HCV) antibodies. Of 130 untreated HCV cases, 53% had normal ALT enzyme levels and half of these were HCV-RNA negative, indicating probable viral clearance.

Older patients on methadone/buprenorphine were significantly more likely to have normal ALT levels and to be HCV-RNA negative. This might be explained by low levels of injecting and hepatitis C re-infection in this group.

Younger patients were less likely to have hepatitis B (HBV) immunity through vaccination or exposure, pointing to the need to target this at-risk group effectively for catch-up vaccination.

Of 58 active hepatitis cases meeting pre-liver biopsy criteria for subsidised HCV treatment, 34 had relative contraindications to antiviral treatment, including drug and alcohol/psychiatric reasons. There were 11 whose only contraindication was continuing to inject. Recent studies show that patients with active injecting drug use can still be successfully treated with HCV antivirals.

At the time of this clinical audit only 6 patients had ever been referred for specialist HCV assessment, however since the end of the study the rate of referral has increased considerably and several patients have completed or commenced HCV treatment, some in the primary care interferon prescribers project of the Australasian Society for HIV Medicine (ASHM).

This study emphasises a unique public health opportunity. The emerging epidemic of hepatitis C is occurring predominantly in the drug using population, thus detection and referral should be possible at methadone clinics, GPs, pharmacies, needle services and injecting rooms frequented by this population. Hence, despite the enormous looming problem of active hepatitis, liver failure and cancer, it is possible that early detection and treatment could avert many of the consequences and save health funds in the long term.

We believe that it is incumbent on all those who treat drug addicts to ensure that their patients have HIV and HCV testing at least annually, and recommend HBV vaccination where appropriate. This is as fundamental as doctors doing cervical cancer smears at certain intervals in appropriate women in the course of normal community practice.

Comments by Andrew Byrne ..