Integrating HCV testing with HIV programs improves hepatitis C outcomes in people who inject drugs: A cluster-randomized trial

Abstract

Background & aims: There have been calls to integrate HCV testing into existing services, including harm reduction and HIV prevention and treatment, but there are few empirical trials to date. We evaluated the impact of integrating HCV testing/education into integrated care centers (ICCs) delivering HIV services to people who inject drugs (PWID) across India, using a cluster-randomized trial.

Methods: We compared ICCs with usual care in the PWID stratum (12 sites) of a 22-site cluster-randomized trial. In 6 sites, ICCs delivering HIV testing, harm reduction, other preventive services and linkage to HIV treatment were scaled from opioid agonist therapy centers and operated for 2 years. On-site rapid HCV antibody testing was integrated after 1 year. To assess impact, we conducted baseline and evaluation surveys using respondent-driven sampling (RDS) across the 12 sites (n = 11,993 recruited at baseline; n = 11,721 recruited at evaluation). The primary outcome was population-level self-reported HCV testing history.

Results: At evaluation, HCV antibody prevalence ranged from 7.2-76.6%. Across 6 ICCs, 5,263 ICC clients underwent HCV testing, of whom 2,278 were newly diagnosed. At evaluation, PWID in ICC clusters were 4-fold more likely to report being tested for HCV than in usual care clusters, adjusting for baseline testing (adjusted prevalence ratio [aPR] 3.69; 95% CI 1.34-10.2). PWID in ICC clusters were also 7-fold more likely to be aware of their HCV status (aPR 7.11; 95% CI 1.14-44.3) and significantly more likely to initiate treatment (aPR 9.86; 95% CI 1.52-63.8).

Conclusions: We provide among the first empirical data supporting the integration of HCV testing into HIV/harm reduction services. To achieve elimination targets, programs will need to scale-up such venues to deliver comprehensive HCV services. CLINICALTRIALS.

Gov identifier: NCT01686750.

Lay summary: Delivering hepatitis C virus (HCV) testing to people who inject drugs (PWID) in places where they also have access to HIV prevention and treatment services is an effective way to improve uptake of HCV testing among communities of PWID. To achieve the World Health Organization's ambitious elimination targets, integrated programs will need to be scaled up to deliver comprehensive HCV services.

Keywords: Cluster-randomised trial; HCV; HIV; Hepatitis C virus; India; Integrated care; PWID; People who inject drugs.

Copyright © 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1.. Cluster-randomized trial design.

ICC: integrated care centers; NACO: National AIDS Control Organisation, India; PWID: people who inject drugs; RDS: respondent driven sampling; UC: usual care.

Fig. 2.. Indian map depicting the absolute percentage point change in ever being tested for HCV between evaluation and baseline assessment by study arm.

Height of triangle is proportionate to the absolute percentage point change at each location. Gray triangle pointing upwards represents a positive change and black triangle pointing downwards represents a negative change.

Fig. 3.. Community-level impact of integrated care centers vs. usual care on HCV care continuum outcomes among PWID in India.

Adjusted prevalence ratios compare the relative likelihood of outcome in the ICC vs. UC clusters. All data presented were estimated using an intent-to-treat (ITT) approach incorporating RDS-2 weights and adjusted for baseline prevalence of outcome.