Background: The arrival of direct-acting antivirals (DAAs) has radically changed the assessment of substance use in HCV treatment decisions. Recent recommendations issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) state that in the modern DAA treatment era recent or active injection-drug use should not be considered a contraindication to HCV treatment and requirements for pretreatment screening for illicit drug or alcohol use should be discontinued. Substance use, which encompasses use of alcohol, marijuana, cocaine, amphetamines, opioids, and other drugs, and the modes of administration (oral, transmucosal, inhaled, and injected), may still be relevant to public health goals of HCV treatment, to adherence support, and to medication access. Substance use is common in the United States, with 2014 data indicating that among persons 12 years of age or older, approximately 10% had used illicit drugs in the past month and approximately 48% had used illicit drugs in their lifetime. The following discussion will address the impact of substance use on HCV disease and potential issues in HCV treatment.
Prior and Active Substance Use and HCV Treatment: The approach to considering initiation of treatment of HCV for individuals with a prior history of substance use, including injecting drugs, should be the same as in patients with no history of drug use. Active substance use, in contrast, may result in payer barriers to accessing HCV treatment, but is not considered a contraindication to DAA-based HCV treatment, particularly when the DAA treatment regimen does not include peginterferon. Indeed, active substance use through injection is considered by many to be a direct indication for HCV treatment due to the potential benefit of reducing secondary HCV transmission.