Blood-borne infections in Dublin's opiate users

Integrating hepatitis C care for at-risk groups (HepLink): baseline data from a multicentre feasibility study in primary and community care

OBJECTIVES

To examine HCV prevalence and management among people who inject drugs (PWID) attending primary care and community-based health services at four European sites using baseline data from a multicentre feasibility study of a complex intervention (HepLink).

METHODS

Primary care and community-based health services in Dublin, London, Bucharest and Seville were recruited from the professional networks of the HepLink consortium. Patients were eligible to participate if aged ≥18 years, on opioid substitution treatment or at risk of HCV (i.e. injecting drug use, homeless or incarcerated), and attended the service. Data on patient demographics and prior HCV management were collected on participants at baseline.

RESULTS

Twenty-nine primary care and community-based health services and 530 patients were recruited. Baseline data were collected on all participants. Participants' mean age ranged from 35 (Bucharest) to 51 years (London), with 71%-89% male. Prior lifetime HCV antibody testing ranged from 65% (Bucharest) to 95% (Dublin) and HCV antibody positivity among those who had been tested ranged from 78% (Dublin) to 95% (Bucharest). Prior lifetime HCV RNA testing among HCV antibody-positive participants ranged from 17% (Bucharest) to 84% (London). Among HCV antibody- or RNA-positive participants, prior lifetime attendance at a hepatology/infectious disease service ranged from 6% (London) to 50% (Dublin) and prior lifetime HCV treatment initiation from 3% (London) to 33% (Seville).

CONCLUSIONS

Baseline assessment of the HCV cascade of care among PWID attending primary care and community-based health services at four European sites identified key aspects of the care cascade at each site that need to be improved.

Hepatitis C virus infection in Irish drug users and prisoners - a scoping review

BACKGROUND

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners.

METHODS

A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O'Malley).

RESULTS

A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients' and Health Providers' Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST.

CONCLUSION

Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

Hepcare Europe - bridging the gap in the treatment of hepatitis C: study protocol

BACKGROUND

Hepatitis C (HCV) infection is highly prevalent among people who inject drugs (PWID). Many PWID are unaware of their infection and few have received HCV treatment. Recent developments in treatment offer cure rates >90%. However, the potential of these treatments will only be realised if HCV identification among PWID with linkage to treatment is optimised. This paper describes the Hepcare Europe project, a collaboration between five institutions across four member states (Ireland, UK, Spain, Romania), to develop, implement and evaluate interventions to improve the identification, evaluation and treatment of HCV among PWID.

METHODS

A service innovation project and a mixed-methods, pre-post intervention study, Hepcare will design and deliver interventions in Dublin, London, Seville and Bucharest to enhance PWID engagement and retention in the cascade of HCV care.

RESULTS

The feasibility, acceptability, potential efficacy and cost-effectiveness of these interventions to improve care processes and outcomes among PWID will be evaluated.

CONCLUSION

Hepcare has the potential to make an important impact on patient care for marginalised populations who might otherwise go undiagnosed and untreated. Lessons learned from the study can be incorporated into national and European guidelines and strategies for HCV.

Determination of the burden of hepatitis C virus infection in Ireland

Information on the burden of hepatitis C virus (HCV) disease is needed to inform policy decisions on primary and secondary prevention. Specimen-based laboratory data (1989–2004) were converted to person-based data and combined with notification data (2004–2009) to describe the burden of HCV infection in Ireland. More than 10 000 people were confirmed as HCV infected in 1989–2004, with the numbers peaking in 2000. The predominant genotypes were 1 (55%) and 3 (39%). Drug use was the most likely risk factor in 80%, with receipt of blood or blood products in 16%. It is estimated that 20 000–50 000 people in Ireland are chronically infected with HCV, a population prevalence of 0·5–1·2%, which is similar to other countries in Northern Europe. This is the first published estimate of the number of chronic HCV infections in Ireland. These data will be of value in health service planning and will contribute to the understanding of HCV infection in Europe.

Barriers to and facilitators of hepatitis C testing, management, and treatment among current and former injecting drug users: a qualitative exploration

Hepatitis C (HCV) infection is common among injecting drug users (IDUs), yet accessing of HCV care, particularly HCV treatment, is suboptimal. There has been little in-depth study of IDUs experiences of what enables or prevents them engaging at every level of HCV care, including testing, follow-up, management and treatment processes. This qualitative study aimed to explore these issues with current and former IDUs in the greater Dublin area, Ireland. From September 2007 to September 2008 in-depth interviews were conducted with 36 service-users across a range of primary and secondary care services, including: two addiction clinics, a general practice, a community drop-in center, two hepatology clinics, and an infectious diseases clinic. Interviews were analyzed using a grounded theory approach. Barriers to HCV care included perceptions of HCV infection as relatively benign, fear of investigations and treatment, and feeling well. Perceptions were shaped by the discourse about HCV and "horror stories" about the liver biopsy and treatment within their peer networks. Difficulties accessing HCV care included limited knowledge of testing sites, not being referred for specialist investigations and ineligibility for treatment. Employment, education, and addiction were priorities that competed with HCV care. Relationships with health care providers influenced engagement with care: Trust in providers, concern for the service-user, and continuity of care fostered engagement. Education on HCV infection, investigations, and treatment altered perceptions. Becoming symptomatic, responsibilities for children, and wanting to move on from drug use motivated HCV treatment. In conclusion, IDUs face multiple barriers to HCV care. A range of facilitators were identified that could inform future interventions.

Hepatitis C virus infection in primary care: survey of registered nurses' knowledge and access to information

AIM

This paper is a report of a study conducted to compare knowledge of hepatitis C virus infection amongst three groups of registered nurses working in primary care, to identify their current sources of information and access to educational resources.

BACKGROUND

Hepatitis C virus infection is a public health problem; no vaccine exists to prevent the disease. Previous studies identified limitations in nurses' knowledge of hepatitis C virus infection and the impact on care. Limited research has been conducted in primary care.

METHODS

A cross-sectional postal census survey of 981 nurses working in one Irish health board region was conducted March-June 2006. Questionnaires measured knowledge of hepatitis C virus infection. Data were collected on demographics, current working practices, information resources and previous education.

RESULTS

The response rate was 57·1% (n = 560). A minority (27·3% 145/531) of respondents agreed they were well informed about the virus. Almost 40% reported having contact with clients with the virus; however, information and service provision differed. Factors influencing higher knowledge included: contact with clients with hepatitis C virus infection (P < 0·0001), working in the addiction services (P < 0·0001), educated to degree level and above (P < 0·010) and previously attending education programmes (P < 0·0001). Only 21·5% (119/553) of respondents had attended any form of education on hepatitis C virus infection.

CONCLUSION

Gaps in nurses' knowledge exist and can limit information and advice. Educational and information resources need to be developed for registered nurses working in primary care; care for clients with hepatitis C virus infection is not the sole remit of the addiction services.

Methadone Maintenance Treatment (MMT) in General Practice or in Specialized Centers: Profile of Patients in the Swiss Canton of Vaud

We studied profile of patients (n=1782) treated in specialized centers and general practice (GP) enrolled in methadone maintenance treatment (MMT) programs during 2001 in the Swiss Canton of Vaud. We found that GPs treated the majority of patients (76%). Specialized centers treated a higher proportion of patients with uncontrolled intravenous use of cocaine and heroin, and prescribed neuroleptics as concomitant medication three times more frequently than GPs. Patients treated in specialized centers were more likely to undergo screening for HIV, HBV, HCV, and receive complete HBV immunization. In conclusion, specialized centers are more likely to treat severely addicted patients and patients with a poor global assessment (physical, psychiatric, and social).

Management of hepatitis C among drug users attending general practice in Ireland: baseline data from the Dublin area hepatitis C in general practice initiative

OBJECTIVE

In Ireland, general practice is increasingly providing long-term care for injecting drug users, 62-81% of whom are infected with hepatitis C (HCV). Clinical guidelines for the management of HCV among drug users have recently been developed in Ireland, and this study aimed to describe HCV care among drug users attending general practice in the greater Dublin area, prior to the implementation of the clinical practice guidelines.

METHODS

The clinical records of 196 patients attending 25 general practices in the Eastern Regional Health Authority area of Ireland for methadone maintenance treatment were examined on site and anonymized data collected on HCV care processes.

RESULTS

Patients had been attending general practice for methadone maintenance treatment for a mean of 30.7 months, 72% were male and 51% had provided a urine sample testing positive for metabolites of drugs of abuse other than methadone in the previous 3 months. There was evidence that 77%, 69% and 60% had been screened for HCV, human immunodeficiency virus (HIV) and hepatitis B (HBV), respectively. Among those who had been tested, the prevalence of HCV, HIV and HBV infection was 69%, 10% and 11%, respectively. Of those known to be HCV positive, 36 (35%) had been tested for HCV-RNA (29 testing positive), 31 (30%) had been referred to a hepatology clinic, 24 (23%) had attended a clinic, 13 (13%) had a liver biopsy performed and three (3%) had started treatment for HCV.

CONCLUSION

While the majority of patients have been screened for blood-borne viruses, a minority of those infected with HCV have had subsequent investigations or treatment. New interventions to facilitate optimum care in this regard need to be considered.

Patients in long-term maintenance therapy for drug use in Italy: analysis of some parameters of social integration and serological status for infectious diseases in a cohort of 1091 patients

BACKGROUND

Heroin addiction often severely disrupts normal social functioning. The aims of this multi-centre study of heroin users in long-term replacement treatment were: i) to provide information on aspects of social condition such as employment, educational background, living status, partner status and any history of drug addiction for partners, comparing these data with that of the general population; ii) to assess the prevalence of hepatitis, syphilis and HIV, because serological status could be a reflection of the social conditions of patients undergoing replacement treatment for drug addiction; iii) to analyse possible relationships between social conditions and serological status.

METHODS

A cross-sectional study was carried out in sixteen National Health Service Drug Addiction Units in northern Italy. The data were collected from February 1, 2002 to August 31, 2002. Recruitment eligibility was: maintenance treatment with methadone or buprenorphine, treatment for the previous six months, and at least 18 years of age. In the centres involved in the study no specific criteria or regulations were established concerning the duration of replacement therapy. Participants underwent a face-to-face interview.

RESULTS

The conditions of 1091 drug treatment patients were evaluated. The mean duration of drug use was 14.5 years. Duration was shorter in females, in subjects with a higher educational background, and in stable relationships. Most (68%) had completed middle school (11-14 years of age). Seventy-nine percent were employed and 16% were unemployed. Fifty percent lived with their parents, 34% with a partner and 14% alone. Males lived more frequently with their parents (55%), and females more frequently with a partner (60%). Sixty-seven percent of male patients with a stable relationship had a partner who had never used heroin. HCV prevalence was 72%, HBV antibodies were detected in 42% of patients, while 30% had been vaccinated; 12.5% of subjects were HIV positive and 1.5% were positive for TPHA.

CONCLUSION

A significant percentage of heroin users in treatment for opiate addiction in the cohort study have characteristics which indicate reasonable integration within broader society. We posit that the combination of effective treatment and a setting of economic prosperity may enhance the social integration of patients with a history of heroin use.

Bloodborne virus infections among drug users in Ireland: a retrospective cross-sectional survey of screening, prevalence, incidence and hepatitis B immunisation uptake

BACKGROUND

Injecting drug users are at high-risk of bloodborne virus infections including hepatitis C (HCV), hepatitis B (HBV) and HIV.

AIMS

To document screening for and immunisation against bloodborne viruses and to determine the known prevalence and incidence of these infections.

METHODS

A cross-sectional survey of clients attending 21 specialist addiction treatment clinics in one health board area in greater Dublin. Data collected on demographic characteristics, serology for HCV, HBV and HIV and immunisation against HBV.

RESULTS

A total of 316 (88%) had been tested for anti-HCV antibody, 244 (68%) had been tested for anti hepatitis B core antibody (anti-HBc), 299 (84%) had been tested for hepatitis B surface antigen (HBsAg) and 307 (86%) had been tested for anti-HIV antibody. The prevalence of anti-HCV, anti-HBc, HBsAg, and anti-HIV were: 66%, 17%, 2% and 11% respectively. The incidence of HCV, HBV and HIV infections were: 24.5, 9.0 and 3.4 per hundred person years respectively. Eighty-one per cent of those in whom it was indicated, had started a targeted HBV immunisation programme in the clinics.

CONCLUSION

The proportion of clients screened for HCV, HBV and HIV infection has increased since the introduction of a screening protocol in 1998. Targeted vaccination for opiate users against hepatitis B is more successful than previously shown in Ireland. The prevalence and incidence of bloodborne viruses remains high among opiate users attending addiction treatment services, despite an increase in availability of harm reduction interventions.

Guidelines for the management of hepatitis C in general practice: a semi-qualitative interview survey of GPs’ views regarding content and implementation

BACKGROUND

Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment.

AIM

To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation.

METHODS

A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines.

RESULTS

GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation.

CONCLUSIONS

Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.

Methadone maintenance treatment in the Swiss Canton of Vaud: demographic and clinical data on 1,782 ambulatory patients

Using data from the Public Health Service, we studied the demographic and clinical characteristics of 1,782 patients enrolled in methadone maintenance treatment (MMT) during 2001 in the Swiss Canton of Vaud, comparing our findings with the results of a previous study from 1976 to 1986. In 2001, most patients (76.9%) were treated in general practice. Mortality is low in this MMT population (1%/year). While patient age and sex profiles were similar to those found in the earlier study, we did observe a substantial increase in the number of patients and the number of practitioners treating MMT patients, probably reflecting the low-threshold governmental policies and the creation of specialized centers. In conclusion, easier access to MMT enhances the number of patients, but new concerns about the quality of management emerge: benzodiazepine as a concomitant prescription; low rates of screening for hepatitis B, C and HIV, and social and psychiatric preoccupations.

Hepatitis C infection among drug users attending general practice

BACKGROUND

The prevalence of hepatitis C (HCV) infection among injection drug users is high and addiction-related care is increasingly being provided by GPs in Ireland.

AIMS

To determine the prevalence and associated factors of HCV infection among injecting drug users attending general practice.

METHODS

The records of 571 patients attending 42 general practices in the Eastern Regional Health Authority (ERHA) area for methadone maintenance treatment were reviewed.

RESULTS

The HCV status was recorded in 380 cases (67%). Of these, 193 had a test performed by their GP, 74 had been tested by another service and 113 had no evidence of being tested, but HCV status was recorded based on information provided by the patient himself. A total of 276 cases were identified as being HCV positive (prevalence 73%), with no difference in prevalence between the three sources of information (p = 0.12). A history of injecting drug use was the major determinant of testing for HCV.

CONCLUSIONS

While a large proportion of drug users attending GPs for methadone maintenance treatment are known to be HCV positive, a considerable number have not been tested. Barriers to testing need to be explored to facilitate comprehensive screening.

Opioids, immunology, and host defenses of intravenous drug abusers

Overall, it is apparent that opioids do affect host defense mechanisms. Heroin users present with an altered and functionally impaired immune system and have a higher prevalence of infectious diseases than do nonaddicts. Individuals exposed to opioid treatment for pain management during surgical procedures or maintained on oral methadone for treatment of drug addiction show either no effect or a suppressed immune system, depending on dosage and, in the case of methadone-maintained patients, duration of drug treatment. Confounding factors in these studies undermine definitive conclusions about the mechanisms by which opioids induce their immunomodulatory effects. Animal models have provided the means by which investigators can study the effects of opioids in a complex, biologic system that is easily manipulated and controlled. Findings from these studies have confirmed human data associating a pathogenic susceptibility with opioid use. Animal models have shown the complexity of this association. Interaction of the CNS, the autonomic nervous system, and the HPA axis is required for the varied effects of opioids on the immune system. By implication, exogenous opioids may be mimicking pathways by which endogenous opioids are involved in regulating immune defenses. To minimize the increased incidence of infectious diseases in heroin users and individuals clinically exposed to opioids, it will be important to determine the individual and collective effects of the opioid-induced activation of these pathways and the consequences of that activation to the immune system.