Global hepatitis C virus (HCV) elimination will require widespread treatment of people who inject drugs (PWID). PWID have historically had limited HCV treatment uptake. Little is known, however, about residual barriers in the direct acting antiviral (DAA) era, particularly in low resource settings, some of which are implementing elimination programs. We examined barriers to HCV treatment among PWID in India, where treatment access is rapidly expanding through generic DAAs (current cost of treatment course: $600 USD).
From 3/15-8/16, participants enrolled in an ongoing community-based cohort of current and former PWID in Chennai, India (n=542) completed a one-time questionnaire on HCV treatment barriers. At biannual follow-up visits, participants underwent a survey and lab testing including HCV & HIV antibody and RNA levels. Descriptive statistics were used to compare characteristics and survey responses.
214 (39.5%) of 542 were HCV-infected and 162 (30%) HCV RNA positive. 28.5% were HIV/HCV coinfected. In a 13-item survey, we found moderate knowledge about HCV disease and treatment among HCV uninfected (mean score=6.55 [standard deviation (SD)=1.30]), HCV monoinfected (mean=6.75 [SD=1.42]; P=0.12) and HCV/HIV coinfected participants (mean=6.31 [SD=0.94]; P=0.03). Only 30% of HIV/HCV coinfected patients knew HCV was curable (compared to 57% of HCV monoinfected). Only 17 participants reported seeing a doctor and 2 a specialist who could treat HCV (total linked to care – 5.6%), 11 (5.1%) initiated and 10 (4.7%) completed treatment. 10 of the 11 with a treatment history were co-enrolled in a clinical trial of HCV treatment. The primary reasons people were not linked were worries/fears about treatment (HCV monoinfected) and competing financial priorities (HIV/HCV coinfected). Factors that improved willingness were pills (vs. injections), perceived efficacy, cost and location with a higher proportion preferring daily visits to a clinic vs. receiving a month’s supply (Figure 1). Willingness to take weekly interferon injections improved substantially with decreasing duration of treatment (60% for 12 weeks vs. 16% for 52 weeks).
These data highlight residual gaps in knowledge and continuing perceptions related to interferon-based therapy, particularly among HIV/HCV coinfected PWID in India. Treatment rollouts need to incorporate educational initiatives and should consider a directly observed therapy (DOT), analogous to what is done for TB.