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To the Editor:

We commend the authors of the updated AASLD Practice Guidelines on hepatitis C virus (HCV) diagnosis, management, and treatment for their clear, comprehensive review.1

However, the Practice Guidelines contain a contradiction about hepatitis C virus (HCV) treatment for active drug users. The information in Table 11 (“Characteristics of Persons for Whom Therapy Should be Individualized”) stipulates that “Current users of illicit drugs or alcohol [who are] willing to participate in a substance abuse program (such as a methadone program) or alcohol support program…..should be abstinent for a minimum period of 6 months prior to initiating HCV treatment.” Elsewhere, the Practice Guidelines recommend consideration of HCV treatment for active drug users, inclusive of persons who currently use illicit drugs and individuals on a methadone maintenance program, “…provided they wish to take HCV treatment and are able and willing to maintain close monitoring and practice contraception.”

Rigid eligibility criteria pose a significant barrier for many candidates regardless of their need for or willingness to engage in HCV treatment; one multiple-city study reported that 96% of young injection drug users were considered ineligible for HCV treatment by conventional criteria.2 Research has demonstrated that certain treatment contraindications are modifiable.3 The literature offers several examples of successful models for delivering HCV care and treatment to active drug users.4-11

We hope that this contradiction is resolved so that the Practice Guidelines are internally consistent in suggesting that clinicians broadly consider HCV treatment for active drug users in the context of supportive, multidisciplinary care.

We thank the authors for their support of more inclusive HCV treatment guidelines.

References

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  • 1
    Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C: an update. HEPATOLOGY 2009; 49: 13351374.
  • 2
    Hagan H, Latka MH, Campbell JV, Golub ET, Garfein RS, Thomas DA, et al.; Study to Reduce Intravenous Exposures Project Team. Eligibility for treatment of hepatitis C virus infection among young injection drug users in 3 US cities. Clin Infect Dis 2006; 42: 669672.
  • 3
    Mehta SH, Thomas DL, Sulkowski MS, Safaein M, Vlahov D, Strathdee SA. A framework for understanding factors that affect access and utilization of treatment for hepatitis C virus infection among HCV-mono-infected and HIV/HCV-co-infected injection drug users. AIDS 2005; 19( Suppl 3): S179S189.
  • 4
    Backmund M, Meyer K, Von Zielonka M, Eichenlaub D. Treatment of hepatitis C infection in injection drug users. HEPATOLOGY 2001; 34: 188193.
  • 5
    Bruggmann P, Falcato L, Dober S, Helbling B, Keiser O, Negro F, et al.; Swiss Hepatitis C Cohort Study. Active intravenous drug use during chronic hepatitis C therapy does not reduce sustained virological response rates in adherent patients. J Viral Hepat 2008; 15: 747752.
  • 6
    Cournot M, Glibert A, Castel F, Druart F, Imani K, Lauwers-Cances V, et al. Management of hepatitis C in active drugs users: experience of an addiction care hepatology unit. Gastroenterol Clin Biol 2004; 28: 533539.
  • 7
    Grebely J, Genoway K, Khara M, Duncan F, Viljoen M, Elliott D, et al. Treatment uptake and outcomes among current and former injection drug users receiving directly observed therapy within a multidisciplinary group model for the treatment of hepatitis C virus infection. Int J Drug Policy 2007; 18: 437443.
  • 8
    Litwin AH, Harris KA Jr, Nahvi S, Zamor PJ, Soloway IJ, Tenore, et al. Successful treatment of chronic hepatitis C with pegylated interferon in combination with ribavirin in a methadone maintenance treatment program. J Subst Abuse Treat 2008; doi:10.1016/j.jsat.2008.09.009.
  • 9
    Nguyen OK, Dore GJ, Kaldor JM, Hellard ME; ATAHC Protocol Steering Committee. Recruitment and follow-up of injecting drug users in the setting of early hepatitis C treatment: insights from the ATAHC study. Int J Drug Policy 2007; 18: 447451.
  • 10
    Robaeys G, Van Vlierberghe H, Matheï C, Van Ranst M, Bruckers L, Buntinx F; BASL Steering Committee; Benelux Study Group. Similar compliance and effect of treatment in chronic hepatitis C resulting from intravenous drug use in comparison with other infection causes. Eur J Gastroenterol Hepatol 2006; 18: 159166.
  • 11
    Sylvestre DL, Zweben JE. Integrating HCV services for drug users: a model to improve engagement and outcomes. Int J Drug Policy 2007; 18: 406410.

Tracy Swan*, Jen Curry†, * Treatment Action Group, New York, NY, † Harm Reduction Coalition, Oakland, CA.