Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 141 No. 2122 (2011)

Management of hepatitis C virus (HCV) infection in drug substitution programs

  • K Hensel-Koch
  • MC Thurnheer
  • P Bruggmann
Cite this as:
Swiss Med Wkly. 2011;141:w13193


BACKGROUND: In Switzerland, intravenous drug use (IDU) accounts for 80% of newly acquired hepatitis C virus (HCV) infections. Early HCV treatment has the potential to interrupt the transmission chain and reduce morbidity/mortality due to decompensated liver cirrhosis and hepatocellular carcinoma. Nevertheless, patients in drug substitution programs are often insufficiently screened and treated.

OBJECTIVE/METHODS: With the aim to improve HCV management in IDUs, we conducted a cross sectional chart review in three opioid substitution programs in St. Gallen (125 methadone and 71 heroin recipients). Results were compared with another heroin substitution program in Bern (202 patients) and SCCS/SHCS data.

RESULTS: Among the methadone/heroin recipients in St. Gallen, diagnostic workup of HCV was better than expected: HCV/HIV-status was unknown in only 1% (2/196), HCV RNA was not performed in 9% (13/146) of anti-HCV-positives and the genotype missing in 15% (12/78) of HCV RNA-positives. In those without spontaneous clearance (two thirds), HCV treatment uptake was 23% (21/91) (HIV-: 29% (20/68), HIV+: 4% (1/23)), which was lower than in methadone/heroin recipients and particularly non-IDUs within the SCCS/SHCS, but higher than in the, mainly psychiatrically focussed, heroin substitution program in Bern (8%). Sustained virological response (SVR) rates were comparable in all settings (overall: 50%, genotype 1: 35–40%, genotype 3: two thirds). In St. Gallen, the median delay from the estimated date of infection (IDU start) to first diagnosis was 10 years and to treatment was another 7.5 years.

CONCLUSIONS: Future efforts need to focus on earlier HCV diagnosis and improvement of treatment uptake among patients in drug substitution programs, particularly if patients are HIV-co-infected. New potent drugs might facilitate the decision to initiate treatment.


  1. Broers B, Helbling B, François A, Schmid P, Chuard Ch, Hadengue A, Negro F, for the Swiss Association for the Study of the Liver (SASL 18). Barriers to interferon-α therapy are higher in intravenous drug users than in other patients with acute hepatitis C. Journal of Hepatology. 2005;42:323–8.
  2. Bruggmann P, Broers B, Meili D. Hepatitis C-Therapie bei Patienten unter Opioidsusbstitution. Empfehlungen der Schweizerischen Gesellschaft für Suchtmedizin (SSMA). Schweiz Med Forum. 2007;7:916–9.
  3. Bruggmann P, Kormann A, Meili D. Heroin substitution: an exception or an expanded feasibility for providing hepatitis treatment to drug users? Hot Topics in Viral Hepatitis. 2009;13:27–33.
  4. Belfiori B, Ciliegi P, Chiodera A, Bacosi D, Tosti A, Baldelli F, et al. Peginterferon plus ribavirin for chronic hepatitic C in opiate addicts on methadone/buprenorphine maintenance therapy. Dig Liver Dis. 2009;41(4):303–7.
  5. Grebely J, de Vlaming S, Duncan F, Vilioen M, Conway B. Current approaches to HCV infection in current and former injection drug users. J Addict Dis. 2008;27(2):25–35.
  6. 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(10):747–52.
  7. Prasad L, Spicher VM, Zwahlen M, Rickenbach M, Helbling B, Negro F and Swiss Hepatitis C Cohort Study Group. Cohort Profile: The Swiss Hepatitis C Cohort Study (SCCS). Int J Epidemiol. 2007;36:731–7.
  8. Mehta SH, Genberg BL, Astemborski J, Kavasery R, Kirk GD, Vlahov D, et al. Limited uptake of hepatitis C treatment among injection drug users. J Community Health. 2008;33(3):126–33.
  9. Martin-Carbonero L, Benhamou Y, Puoti M, Berenguer J, Mallolas J, Quereda C, et al. Incidence and predictors of severe liver fibrosis in HIV infected patients with chronic hepatitis C: a European collaborative study. Clin Infect Dis. 2004;38:128–33.
  10. Martinez-Sierra C, Arizcorreta A, Diaz F, Roldan R, Martin-Herrera L, Perez-Guzman L, et al. Progression of chronic hepatitis C to liver fibrosis and cirrhosis in patients coinfected with hepatitis C virus and HIV. Clin Infect Dis. 2003;36:491–8.
  11. Marin-Carbonero L, Soriano V, Valencia E, Garcia-Samaniego J, Lopez M, Gonzalez-Lahoz J. Increasing impact of chronic viral hepatitis on hospital admissions and mortality among HIV-infected patients. AIDS Res Hum Retroviruses. 2001;17:1467–72.
  12. Bica I, McGovern B, Dhar R, McGowan K, Scheib R, Snydman D. Increasing mortality due to end-stage liver disease in patients with HIV-infection. Clin Infect Dis. 2001;32:492–7.
  13. Weber R, Sabin CA, Friis-Møller N, Reiss P, El-Sadr WM, Kirk O, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med. 2006;166(15):1632–41.
  14. Rosenthal E, Samon-Céron D, Lewden C, Bouteloup V, Pialoux G, Bonnet F, et al. Liver-related deaths in HIV-infected patients between 1995 and 2005 in the French GERMIVIC Joint Study Group Network (Mortavic 2005 study in collaboration with the Mortalité 2005 survey, ANRS EN 19). HIV Med. 2009;10(5):282–9.
  15. Grebely J, Raffa JD, Meagher C, Duncan F, Genoway KA, Khara M, et al. Directly observed therapy for the treatment of hepatitis C virus infection in current and former injection drug users. J Gastroenterol Hepatol. 2007;22(9):1519–25.
  16. Grebely J, Genoway K, Khara M, Duncan F, Vilioen M, Elliott D, et al. Treatment uptakes 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(5):437–43.
  17. Schoeni-Affolter F, et al. Cohort Profile: The Swiss HIV Cohort Study. Int J Epidemiol. 2010;39:1179–89.
  18. Schulthess K, Valkova K, Hauri D, Bachmann L, Steurer J, Seidenberg A. Hepatitis C infections in opioid-dependent patients (HepCOP1): a represenative survey on the state of care in the canton of Zurich. Schweiz Med Forum. 2008;8(Suppl 41):21.
  19. Tuaillon E, Mondain AM, Meroueh F, Ottomani L, Picot MC, Nagot N, et al. Dried blood spot for hepatitis C virus serology and molecular testing. Hepatology. 2010;51:752–8.
  20. Wong JB. Hepatitis C: cost of illness and considerations for the economic evaluation of antiviral therapies. Pharmacoeconomics. 2006;24(7):661–72.
  21. Hornberger J, Torriani FJ, Dieterich DT, Bräu N, Sulkowski MS, Torres MR, et al. Cost-effectiveness of peginterferon alfa-2a (40kDa) plus ribavirin in patients with HIV and hepatitis C virus co-infection. J Clin Virol. 2006;36(4):283–91.
  22. Volk MI, Tocco R, Saini S, Lok AS. Public health impact of antiviral therapy for hepatitis C in the United States. Hepatology. 2009;50:1750–5.
  23. Sheerin IG, Green FT, Sellman JD. The costs of not treating hepatitis C virus infection in injecting drug users in New Zealand. Drug and Acohol Review. 2003;22:159–67.
  24. Telser H, Müllhaupt B, Helbling B, Zweifel P. Kostenvergleich zwischen zwei Kombinationstherapien gegen Hepatitis C mit pegyliertem Interferonen und Ribavirin. Praxis. 2005;94(32):1207–14 (Available from:
  25. BAG [homepage on the Internet]. Kosten der Transplantationsmedizin. [cited 2010 Jul 7]. Available from:
  26. National Institute of Health. NIH Consensus Statement on management of hepatitis C: 2002. NIH Consens State Sci Statements. 2002;19:1–46.
  27. Dhumeaux D, Marcellin P, Lerebours E. Treatment of hepatitis C. the 2002 French consensus. Gut. 2003;52:1784–7.
  28. Overbeck K, Dufour JF, Müllhaupt B, Helbling B, Borovicka J, Malinverni R, et al. Impact of international consensus guidelines on antiviral therapy of chronic hepatitis C patients in Switzerland. Swiss Med Wkly. 2010;140(9-10):146–52.
  29. Bochud PY, Cai T, Overbeck K, Bochud M, Dufour JF, Müllhaupt B, et al. Genotype 3 is associated with accelerated fibrosis progression in chronic hepatitis C. J Hepatol. 2009;51(4):655–66.
  30. Matthews GV, Dore GJ. HIV and hepatitis C coinfection. J Gastroenterol Hepatol. 2008;23(7 Pt 1):1000–8.
  31. Bruggmann P, Dampz M, Gerlach T, Kravecz L, Falcato L. Treatment outcome in relation to alcohol consumption during hepatitis C therapy: an analysis of the Swiss Hepatitis C Cohort Study. Drug Alcohol Depend. 2010;110(1-2):167–71.
  32. Kamal SM, Fouly AE, Kamel RR, Hockenjos B, Al Tawil A, Khalifa KE, et al. Peginterferon alfa-2b therapy in acute hepatitis C: impact of onset of therapy on sustained virologic response. Gastroenterology. 2006;131(3):632–8.
  33. Matthews GV, Helard M, Haber P, Yeung B, Marks P, Baker D, et al. Characteristics and treatment outcomes among HIV-infected individuals in the Australian Trial in Acute Hepatitis C. Clin Infect Dis. 2009;48:650–8.
  34. Romero-Gomez M, Del Mar Viloria M, Andrade RJ, Salmeron J, Diago M, Fernandez-Rodriguez CM, et al. Insulin resistance impairs sustained response rate to peginterferon plus ribavirin in chronic hepatitis C patients. Gastroenterology. 2005;128:636–41.
  35. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis: an update. Hepatology. 2009;49(4):1335–73.
  36. Garfein RS, Vlahov D, Galai N, et al. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human t-lymphotropic viruses. Am J Public Health. 1996;86:655–61.
  37. Thorpe LE, Quellet LJ, Levy JR, et al. Hepatitis C virus infection: prevalence, risk factors and prevention opportunities among young injection drug users in Chicago, 1997–1999. J Infect Dis. 2000;182:1588–94.
  38. Rustgi VK. The epidemiology of hepatitis C infection in the United States. J Gastroenterol. 2007;42:513–21.
  39. Wiley TE, McCarthy M, Breidi L, McCarthy M, Layden TJ. Impact of alcohol on the histological and clinical progression of hepatitis C infection. Hepatology. 1998;28(3):805–9.
  40. Hézode C, Roudot-Thoraval F, Nguyen S, Grenard P, Julien B, Zafrani ES, et al. Daily cannabis smoking as a risk factor for progression of fibrosis in chronic hepatitis C. Hepatology. 2005;42(1):63–71.
  41. Ishida JH, Peters MG, Jin C, Louie K, Tan V, Bacchetti P, et al. Influence of cannabis use on severity of hepatitis C disease. Clin Gastroenterol Hepatol. 2008;6(1):69–75.
  42. Chu CJ, Lee SD. Hepatitis B virus/hepatitis C virus coinfection: epidemiology, clinical features, viral interactions and treatment. J Gastroenterol Hepatol. 2008;23(4):512–20.
  43. Thompson A, Patel K, Tillman H, McHutchison JG. Directly acting antivirals for the treatment of patients with hepatitis C infection: a clinical development update addressing key future challenges. J Hepatol. 2009;50(1):184–94.
  44. Forns S, Marcellin P, Ferenci P, Göser T, Nevens F, Carosi G, et al. On-treatment response-guided therapy with telaprevir q8h or q12h combined with peginterferon alfa-2a or peginterferon alfa-2b and ribavirin in treatment-naive genotype 1 hepatitis C (study C208). J Hepatol. 2010;52(Suppl 1):S26.
  45. Shehab TM, Sonnad SS, Lok AS. Management of hepatitis C patients by primary care physicians in the USA: results of a national survey. J Viral Hepat. 2001;8:377–83.
  46. Persico M, Persico E, Suozzo R, Conte S, De Seta M, Coppola L, et al. Natural history of hepatitis C virus carriers with persistently normal aminotransferase levels. Gastroenterology. 2000;118:760–4.
  47. Gonvers JJ, Heim MH, Cavassini M, Müllhaupt B, Genne D, Bernasconi E, et al. Treamtent of hepatitis C in HCV mono-infected and in HIV-HCV co-infected patients: an open-labelled comparison study. Swiss Medical Wkly. 2010 (early online publication 14.6.2010).
  48. Zinkernagel AS, von Wyl V, Ledergerber B, Rickenbach M, Furrer H, Battegay M, et al. Eligibility for and outcome of hepatitis treatment of HIV-coinfected individuals in clincial practice: the Swiss HIV cohort study. Antiviral Therapy. 2006;11:131–42.