Reinfections are a reality of hepatitis C work. Direct-acting antivirals cure hepatitis C, but being cured does not result in immunity to hepatitis C: a person can get hepatitis C again if they are exposed to the virus. For most people, the risk of reinfection is low, but because of the possibility of reinfection after cure, some healthcare providers have been hesitant to provide hepatitis C treatment to individuals with ongoing risks for infection. De-stigmatizing reinfection and understanding what reinfection rates can tell us about who hepatitis C programs are reaching is essential for advancing hepatitis C care.
This article will establish an understanding of what reinfections are, examine the realities of reinfection rates across affected populations and explore effective strategies to address reinfections across the cascade of hepatitis C care.
What are hepatitis C reinfections?
A person can get hepatitis C again if they are exposed to the virus after they are cured with treatment or have cleared the virus on their own. This is called reinfection. Reinfections follow the same principles as a primary (first) hepatitis C infection — they are transmitted through blood-to-blood contact (e.g., sharing equipment for injecting drugs) and are cured through treatment with direct-acting antivirals (DAAs). The cure rate for treatment of hepatitis C reinfections is as high as it is for treatment of a primary (first) hepatitis C infection.
Populations most impacted by reinfection.
For most people, the risk of hepatitis C reinfection is low. The majority of people who are cured through treatment do not experience hepatitis C reinfection. However, reinfection can happen among people who have ongoing risks for hepatitis C after they have been treated and cured.
Research indicates that hepatitis C reinfection is more common among people who inject drugs, as well as gay, bisexual and other men who have sex with men (gbMSM) who use injection drugs and/or who have HIV.
These groups face a greater likelihood of reinfection because they have a combination of ongoing risk factors for hepatitis C infection and are disproportionally impacted by structural and social factors (such as criminalization of and stigma from drug use) that can hinder their access to healthcare and prevention services, such as needle and syringe programs and condoms.
Hepatitis C reinfection among people who inject drugs
Research shows that among people who inject drugs, the rate of hepatitis C reinfection is highest among people with recent injection drug use (within six months before starting treatment, during treatment, at the end of treatment or during post-treatment follow-up) and lowest among people who are receiving opioid agonist treatment (OAT) independent of drug use. This is shown in a meta-analysis of 36 studies (nine of which were conducted in Canadian contexts) that estimated the rate of hepatitis C reinfection after treatment among different groups of people who use drugs.
The meta-analysis found:
5.9 hepatitis C reinfections per 100 person-yearsa among people with recent drug use (injecting or non-injecting)
6.2 hepatitis C reinfections per 100 person-years among people who had recently injected drugs
3.8 hepatitis C reinfections per 100 person-years among people receiving OAT, independent of drug use6
Further, the meta-analysis found that although reinfection after successful treatment of hepatitis C sometimes occurs, the rate of reinfection among people with recent injection drug use is lower than the rate of primary (first) hepatitis C infections in this population (6.2 infections per 100-person years vs. 23 infections per 100-person years).6
People who inject drugs in prison contexts
People who inject drugs in prison settings have a higher rate of hepatitis C reinfection than people who inject drugs in the general population.6,7,8 This can be linked to having limited or no access in prison environments to harm reduction services to prevent hepatitis C transmission, namely access to harm reduction supplies that would reduce sharing of equipment.
Hepatitis C reinfection among gay, bisexual and other men who have sex with men
Research shows that among gbMSM, injection drug use and living with HIV are both associated with an increased risk of hepatitis C reinfection.5,10 A Canadian cohort study using data from approximately 1.7 million individuals tested for hepatitis C and HIV in British Columbia estimated a reinfection rate of 1.88 reinfections per 100 person-years for gbMSM.10 Among gbMSM living with HIV, the reinfection rate was 3.13 reinfections per 100 person-years. Among gbMSM who used injection drugs, the reinfection rate was 3.25 per 100 person-years.10
How do reinfections impact hepatitis C care?
The benefits of treating hepatitis C reinfections
All people deserve the health and well-being benefits of hepatitis C treatment for a primary infection or a reinfection. These include reduced risks of long-term health impacts such as cirrhosis (advanced liver injury), liver cancer, liver failure and liver-related death. Further, engaging in hepatitis C care can provide additional benefits to individuals, such as access to other care and supports, including harm reduction services or connection to other services, including housing.
Access to treatment for reinfection is also important for population health.11 A treatment-as-prevention approach, which can be considered a cure-as-prevention approach with hepatitis C, diagnoses and treats both primary infections and reinfections early to help prevent onward transmission of hepatitis C, reduce the population prevalence of hepatitis C and reduce morbidity and mortality related to liver disease.11
Hesitancy to treat people at ongoing risk for reinfection
Some have perceived Hepatitis C reinfections after treatment and cure as a treatment failure. These perceptions can have damaging effects as they have sometimes resulted in treatment being withheld from individuals with ongoing risks12 despite universal treatment recommendations.13,14 This is largely due to the high cost of hepatitis C treatment and concern about the potential repeated cost of treatment for reinfection, and in some cases it may be due to restrictive or unclear treatment coverage policies for hepatitis C reinfection.
Normalizing reinfections as a reality of the hepatitis C response
Recently, there has been a push to consider how reinfections can be accepted as a reality of hepatitis C work — emphasizing the benefits of treatment for all and repositioning reinfections as a useful performance indicator. If treatment is universally offered for reinfections and reinfections are seen as an opportunity to strengthen programs, they could be used to better understand the effectiveness of interventions across the care cascade:
Reinfections can confirm whether community health programs are reaching individuals at risk for reinfection. If no cases of reinfection are seen, it is possible that those clients at the highest risk of hepatitis C reinfection are not being reached for testing and treatment. Alternatively, low numbers of people with reinfection can also be used as a measure of effective population-level access to treatment and prevention.
Reinfection can be used to identify groups with a higher burden of hepatitis C and tailor interventions accordingly.
Reinfections may also indicate where there may be barriers to accessing prevention strategies. Persistent reinfections may indicate that prevention strategies could be strengthened and expanded.
Information culled from here.