Supporting Treatment Outcomes Among PWID

The primary objective is to evaluate whether the intensity of treatment adherence support affects sustained virologic response rates in HCV mono- and HIV/HCV co-infected participants receiving HCV direct-acting antivirals (DAA) in PWID-focused centers. Secondary objectives are: 1. To evaluate whether the intensity of treatment adherence support affects HCV treatment completion rates. 2. To evaluate whether the intensity of treatment adherence support affects HCV treatment adherence. 3. To estimate the incidence and correlates of HCV reinfection among HCV mono- and HIV/HCV coinfected PWID who achieve HCV cure. 4. To evaluate the impact of HCV cure on HIV viral suppression among HIV/HCV coinfected PWID.

Investigators will evaluate this via a 3-arm, individual-level randomized clinical trial, in which treatment assignment probabilities vary according to participants' estimated propensity for treatment failure at baseline (precision randomization). An estimated 3,000 persons will be enrolled and randomized at 7 community-based integrated care centers (ICCs) across India across a duration of 18 - 24 months. Data from these 7 ICCs on early HIV treatment refills/viral suppression (3-6 months after antiretroviral therapy (ART) initiation) will be used to develop and validate an algorithm to predict propensity for HCV treatment failure. Prior to treatment initiation, each participant will undergo a questionnaire to capture information on barriers/ facilitators to treatment adherence identified in the prediction model in order to determine the propensity for HCV treatment failure (minimal or elevated risk). Individuals will be preferentially randomized to the support level that matches their failure risk. Those at elevated risk for treatment failure will be randomized at an allocation ratio of 3:2:1 for Arm 3 (high intensity support), Arm 2 (medium intensity support) and Arm 1 (low intensity support), respectively. Conversely, those at minimal risk will be randomized at a ratio of 1:2:3 to Arm 3 (high intensity support), Arm 2 (medium intensity support) and Arm 1 (low intensity support), respectively. Participants and study staff will be blinded to the risk classification (minimal, elevated) but, because of the nature of the interventions, blinding to intervention assignment is not possible.

Persons will be treated for HCV according to the standard of care in India. Minimal laboratory monitoring will be used except when clinically indicated. Participants with decompensated cirrhosis will be excluded from treatment.

All HIV/HCV co-infected participants and those HCV monoinfected participants who achieve SVR will be followed post-treatment. These individuals will be followed every six months after the SVR assessment to assess HCV reinfection and HIV viral suppression (among HIV/HCV coinfected participants) for up to 30 months after SVR.

• Low intensity HCV treatment adherence support (Behavioral): A 28-day supply of medication will be dispensed to participants at entry, 4 weeks, and 8 weeks. Participants will receive standard adherence counseling at entry and every refill pickup/home or field delivery. Participants will have access to all of the services available at the ICC including facilitated linkage to referrals as needed. Site staff will routinely track clients who miss refill appointments in real-time using standard tracking measurements
• Medium intensity HCV treatment adherence support (Behavioral): The medium intensity intervention will include standard of care dispensation of a 28-day supply of medication at entry, 4 weeks and 8 weeks. Participants will be assigned to a patient navigator (PN) and receive tailored patient navigation support for medication reminders, picking up medication refills (or home or field delivery of study medications), overcoming barriers as well as service linkage. Participant will be contacted by the PN at least once every two weeks.
• High intensity HCV treatment adherence support (Behavioral): The high intensity intervention will involve patient-centered DOT with flexibility in terms of the frequency of pickup and the site of DOT (ICC, field-based) with a minimum of at least 1 observed dose per week. Participants in this arm will also receive PN support for overcoming barriers and service linkage similar to participants in Arm 2. The main differences between Arms 2 and 3 are: (i) medications will not be dispensed for more than one week at a time (to coincide with opioid agonist therapy (OAT) dosing, where applicable); and (ii) ≥1 dose/week will be observed.

Primary outcomes

• Sustained Virologic Response (SVR) by Intervention Group Stratified by Defined Risk for Treatment Failure (Minimal vs Elevated) [Between 10 and 60 weeks after scheduled end of treatment.]: The percentage of participants who achieved SVR defined as HCV RNA < lower limit of quantification (LLOQ). HCV RNA < lower limit of quantification (LLOQ, 30 IU/ml) was measured 12 weeks (range 10 - 60 weeks) after treatment completion.

Secondary outcomes

• HCV Treatment Completion [Measured at the end of prescribed course of treatment (12 or 24 weeks)]: The percentage of participants who completed the prescribed course of treatment (12 or 24 weeks). Participants with compensated cirrhosis and genotype 3 infection would have received 24 weeks of treatment. All other participants would have received treatment for 12 weeks. All participants in this study received 12 weeks of treatment.
• Adherence >90% (Self-report) [Measured at the end of prescribed course of treatment (12 or 24 weeks)]: The percentage of participants who self-report taking >90% of doses during treatment.
• Adherence >90% (Medication Records) [Measured at the end of prescribed course of treatment (12 or 24 weeks)]: The percentage of participants in possession of >90% of doses during treatment based on medication refills and pill counts.
• Adherence Level (Self-report) [Measured at the end of prescribed course of treatment (12 or 24 weeks)]: The percentage of doses taken during treatment as self-reported by the participant.
• Adherence Level (Medication Records) [Measured at the end of prescribed course of treatment (12 or 24 weeks)]: The percentage of doses participants had in their possession during treatment based on medication refills and pill counts.
• HCV Reinfection [Measured at 6 month intervals after confirmation of SVR for up to 36 months.]: The percentage of participants who test positive for HCV Core Antigen after achieving SVR.
• HIV Viral Suppression Among HIV/HCV Coinfected Participants [After assessment of SVR for up to 36 months.]: The percentage of HIV/HCV co-infected participants with HIV RNA less than LLOQ after the SVR assessment. HCV RNA abstracted from chart reviews.

Other outcomes

• Exploratory Outcome Measure: Medication for Opioid Use Disorder (MOUD) Initiation [Measured daily from Entry Visit to post SVR for up to 36 months]: Rate of MOUD Initiation post randomization
• Exploratory Outcome Measure: Medication for Opioid Use Disorder Retention [Measured daily from Entry Visit to post SVR for up to 36 months]: Consistent MOUD use post randomization
• Exploratory Outcome Measure: Quality of Life [Measured at 6 month intervals at the SVR visit and post SVR for up to 36 months.]: Self-reported quality of life score based on self-report
• Exploratory Outcome Measure: Mortality [Measured from Entry visit to post SVR for up to 36 months.]: Mortality rate per person years
• Exploratory Outcome Measure: Cost Effectiveness of Tailored Support Options (Low, Medium and High Intensity) [Measured at weekly intervals starting from Entry visit to SVR visit (up to 12 weeks after treatment completion).]: Incremental cost effectiveness ratios calculated between an intervention and its next least costly comparator and assessed against per capita Gross Domestic Product (GDP)
• Exploratory Outcome Measure: Acceptability of Low, Medium and High Intensity Interventions [Qualitative interviews will be conducted between the end of treatment visit and the SVR visit (up to 12 weeks after treatment completion).]: Measured by in-depth qualitative interviews with integrated care clinic staff and clients post intervention.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Registered for care at an Integrated Care Center (ICC) in one of the 7 field sites.
* Active HCV infection confirmed by a detectable HCV RNA by polymerase chain reaction (PCR) (HCV RNA ≥ 30 copies/ml) within 90 days prior to study entry.
* Liver disease stage defined as non-cirrhotic or compensated cirrhotic (metric/diagnostic criteria used for fibrosis staging) within 90 days prior to study entry.

  i. Albumin >3.0 g/L. ii. Hemoglobin >8.0 g/dL for women; >9.0 g/dL for men. iii. Platelet count >50,000/mm3. iv. Calculated creatinine clearance (CrCl) using Cockcroft-Gault method >30 mL/min. v. Aspartate aminotransferase (AST/SGOT) <10 times the upper limit of the normal range (ULN). vi. Alanine aminotransferase (ALT/SGPT) <10 times the ULN. vii. Total bilirubin <1.5 times the ULN for participants not on atazanavir (ATV) and <3 times the ULN for participants on ATV. viii. International normalized ratio (INR) <1.5 times the ULN.
* Life expectancy greater than 1 year (as determined by study clinician)
* Willing to initiate HCV treatment
* Agree to be randomized to an adherence support strategy
* Ability and willingness to provide written informed consent
* Female participants of reproductive potential must not be pregnant
* All female participants of reproductive potential must agree not to participate in a conception process
* All female participants of reproductive potential must agree to use at least one reliable form of contraceptive while receiving protocol-specified medication, and for 6 weeks after stopping the medication.

Exclusion Criteria:

* Psychologically unfit to provide written informed consent.
* Planning to migrate within the next six months.
* Known allergy/sensitivity or any hypersensitivity to components of study drug(s) or their formulation.
* Acute or serious illness requiring systemic treatment and/or hospitalization within 30 days prior to study entry.
* In HIV positive participants, presence of active or acute AIDS-defining opportunistic infections within 30 days prior to study entry.
* Use of prohibited medications within the past 14 days prior to study entry.
* Evidence of decompensated liver disease on clinical exam.
* Evidence of active tuberculosis.
* Evidence of chronic hepatitis B infection (HBsAg positive).
* Currently on HCV treatment.
* Prior history of DAA-based HCV treatment
* Confirmed active SARS CoV-2 infection or suspected active SARS CoV-2 infection at enrollment.
* Currently nursing (breastfeeding).

Participant flow

Outcome results

• Sustained Virologic Response (SVR) by Intervention Group Stratified by Defined Risk for Treatment Failure (Minimal vs Elevated) (Primary), Count of participants, Participants: Arm 1: Low Intensity Intervention (Minimal Risk) 638; Arm 2: Medium Intensity Intervention (Minimal Risk) 416; Arm 3: High Intensity Intervention (Minimal Risk) 233; Arm 1 : Low Intensity Intervention (Elevated Risk) 76; Arm 2: Medium Intervention (Elevated Risk) 145; Arm 3: High Intensity Intervention (Elevated Risk) 241
• HCV Treatment Completion (Secondary), Count of participants, Participants: Arm 1: Low Intensity Intervention (Minimal Risk) 969; Arm 2: Medium Intensity Intervention (Minimal Risk) 660; Arm 3: High Intensity Intervention (Minimal Risk) 311; Arm 1 : Low Intensity Intervention (Elevated Risk) 138; Arm 2: Medium Intervention (Elevated Risk) 291; Arm 3: High Intensity Intervention (Elevated Risk) 413
• Adherence >90% (Self-report) (Secondary), Count of participants, Participants: Arm 1: Low Intensity Intervention (Minimal Risk) 860; Arm 2: Medium Intensity Intervention (Minimal Risk) 595; Arm 3: High Intensity Intervention (Minimal Risk) 284; Arm 1 : Low Intensity Intervention (Elevated Risk) 105; Arm 2: Medium Intervention (Elevated Risk) 239; Arm 3: High Intensity Intervention (Elevated Risk) 372
• Adherence >90% (Medication Records) (Secondary), Count of participants, Participants: Arm 1: Low Intensity Intervention (Minimal Risk) 755; Arm 2: Medium Intensity Intervention (Minimal Risk) 541; Arm 3: High Intensity Intervention (Minimal Risk) 234; Arm 1 : Low Intensity Intervention (Elevated Risk) 99; Arm 2: Medium Intervention (Elevated Risk) 233; Arm 3: High Intensity Intervention (Elevated Risk) 305
• Adherence Level (Self-report) (Secondary), Median, % of doses taken: Arm 1: Low Intensity Intervention (Minimal Risk) 100 (98.7 to 100); Arm 2: Medium Intensity Intervention (Minimal Risk) 100 (100 to 100); Arm 3: High Intensity Intervention (Minimal Risk) 100 (100 to 100); Arm 1 : Low Intensity Intervention (Elevated Risk) 100 (83.3 to 100); Arm 2: Medium Intervention (Elevated Risk) 100 (90.0 to 100); Arm 3: High Intensity Intervention (Elevated Risk) 100 (93.3 to 100)
• Adherence Level (Medication Records) (Secondary), Median, Percentage of doses: Arm 1: Low Intensity Intervention (Minimal Risk) 96.5 (89.4 to 98.8); Arm 2: Medium Intensity Intervention (Minimal Risk) 96.6 (91.3 to 98.8); Arm 3: High Intensity Intervention (Minimal Risk) 95.2 (87.4 to 98.8); Arm 1 : Low Intensity Intervention (Elevated Risk) 93.3 (85.6 to 97.6); Arm 2: Medium Intervention (Elevated Risk) 95.5 (89.2 to 98.8); Arm 3: High Intensity Intervention (Elevated Risk) 92.9 (84.9 to 97.6)
• HCV Reinfection (Secondary)
• HIV Viral Suppression Among HIV/HCV Coinfected Participants (Secondary)
• Exploratory Outcome Measure: Medication for Opioid Use Disorder (MOUD) Initiation (Other pre specified)
• Exploratory Outcome Measure: Medication for Opioid Use Disorder Retention (Other pre specified)
• Exploratory Outcome Measure: Quality of Life (Other pre specified)
• Exploratory Outcome Measure: Mortality (Other pre specified)
• Exploratory Outcome Measure: Cost Effectiveness of Tailored Support Options (Low, Medium and High Intensity) (Other pre specified)
• Exploratory Outcome Measure: Acceptability of Low, Medium and High Intensity Interventions (Other pre specified)

Adverse events

Time frame: From date of randomization up to the expected Sustained Virologic Response (SVR) 12 week visit date

Serious adverse events by term

Other adverse events by term

• Results publication: Solomon SS, Srikrishnan AK, McFall AM, Baishya J, Gunaratne MP, Kedar A, Amrose P, Balakrishnan R, Boobalan J, Evans J, Lau BM, Ehrhardt S, Sulkowski MS, Thomas DL, Lucas GM, Suresh Kumar M, Mehta SH. A precision randomized trial of hepatitis C treatment support among people who inject drugs in India: The STOP-C Trial. J Hepatol. 2026 Jun 30:S0168-8278(26)02683-8. doi: 10.1016/j.jhep.2026.06.034. Online ahead of print. PMID 42379314
• Results publication: Mehta SH, Lau BM, Ehrhardt S, McFall A, Gunaratne MP, Baishya J, Kedar A, Srikrishnan AK, Evans J, Loeb T, Pradeep A, Kumar MS, Thomas DL, Lucas GM, Solomon SS. A precision randomized trial to evaluate the impact of tailored hepatitis C treatment adherence support on HCV treatment outcomes among people who inject drugs in India: design and baseline characteristics of the STOP-C trial. Am J Epidemiol. 2025 Oct 7;194(10):2986-2998. doi: 10.1093/aje/kwae430. PMID 39572371

• Study Protocol (PDF, 2022-06-30)
• Statistical Analysis Plan (PDF, 2024-01-05)

• Sunil S Solomon, PhD MBBS MPH, Principal investigator, Johns Hopkins University School of Medicine and Y.R. Gaitonde Centre for AIDS Research and Education
• Shruti H Mehta, PhD MPH, Principal investigator, Johns Hopkins Bloomberg School of Public Health

NIH grants: R01AI145555