Hepatitis C update

"It gives me a sense of belonging": providing integrated health care and treatment to people with HCV engaged in a psycho-educational support group

BACKGROUND

Injection drug use (IDU) increases the risk of contracting hepatitis C virus (HCV) yet very few people living with HCV access effective, and potentially curative, treatments. The East Toronto Hepatitis C Program (ETHCP) was developed in 2006 and provides health care, treatment and support to people living with HCV who have complex mental health, physical health and psychosocial needs. The program is anchored in a 16-18 week psychosocial support group located within one of the 3 participating community-based health clinics. The objective of this study was to explore the experiences of individuals engaged in the ETHCP psycho-educational group.

METHODS

This phenomenological qualitative study consisted of semi-structured in-depth interviews with twenty randomly selected program participants.

RESULTS

The three dominant themes that emerged from the analysis were program structure, group cohesion and group as agent for change. The ETHCP "one-stop shopping" model provided a stable foundation allowing for the development of group cohesion. Group cohesion was marked by the formation of intense relationships creating a safe and non-judgmental environment where participants could self-reflect, make social connections and feel cared for and accepted. Three types of relationships characterized group cohesion: relationship to self, relationships with individual group members and relationship to group as a whole. Within the nurturing group environment, participants could challenge themselves and others, ultimately enabling change.

CONCLUSION

The results of our qualitative study suggest that it is the formation of strong group cohesion that facilitated participants' behavioural change, regardless of their level of substance use. The structure of the group provided stability and was characterized by consistent weekly meetings, knowledge exchange and the provision of multiple services in one location. The support from peers and staff allowed participants to develop personal goals. Participants began to see themselves in a new and changed way; expressing this change in a variety of positive behaviours.

Increasing public awareness about hepatitis C: development and validation of the brief hepatitis C knowledge scale

Hepatitis C virus (HCV) is silently becoming a major public health problem. Currently, no validated HCV knowledge measures exist. This study aimed to develop and validate a brief measure to assess general knowledge about HCV risk factors, modes of transmissions, and treatment options. A total of 406 individuals participated in this cross-sectional study. All participants completed the proposed 19-item Brief HCV Knowledge Scale. Participants were: HCV mono-infected patients (n = 83), HCV-human immunodeficiency virus (HIV) co-infected patients (n = 24), HIV mono-infected patients (n = 128) community healthcare workers (n = 89), and college students (n = 82). Two-week test-retest data were collected for the college student sample. Psychometric evaluation of the proposed scale demonstrated high levels of validity (content and construct validity) and reliability (internal consistency and retest stability). Factor analysis indicated a one-factor solution, which accounted for 49% of the variance. HCV knowledge was positively correlated with length of time since HCV diagnosis (r = 0.29, p < 0.05). HCV treatment-experienced patients obtained significantly higher HCV knowledge scores (82% correct) than HCV treatment-naïve patients (72% correct) (p < 0.05). HCV knowledge in College students (43% correct) and HIV patients (54% correct) was significantly lower than in HCV patients (77% correct) and community healthcare workers (80% correct) (p < 0.001). Community workers' HCV knowledge was positively correlated with years of HCV work experience (r = 0.30, p < 0.01). This self-administered Brief HCV Knowledge scale has high levels of validity and reliability across patient, healthcare provider and college student populations. It has valuable applications as a clinical teaching tool with patients and healthcare providers and could be used as an outcome indicator in novel HCV educational intervention studies.

Harm reduction product distribution in British Columbia

OBJECTIVES

The British Columbia Centre for Disease Control (BCCDC) tracks the distribution of all harm reduction products subsidized by the BC government, including needles and syringes, sterile water vials, alcohol swabs, condoms, and lubricant. This study measures the distribution of harm reduction products in BC, identifies regional variation in distribution, and estimates the supply/demand ratio for needle and syringe units.

METHODS

Using three years of administrative data (2004-2006) from the BCCDC, the quantity of harm reduction products distributed was calculated by Health Service Delivery Area (HSDA). Regional hepatitis C virus (HCV) case report rates were calculated to reflect potential variation in IDU populations at the HSDA-level and the number of needle and syringe units distributed per reported case of HCV was calculated and ranked by HSDA. To compare the demand for sterile injecting equipment to the distribution, the number of illicit drug injections per year was approximated using established estimates of IDU populations in BC and Vancouver.

RESULTS

Marked regional variation exists in the rates of harm reduction product distribution per 100,000 residents aged 15-64. The average number of needle and syringe units distributed annually in BC from 2004-2006 was 5,382,933. The estimated number of injections per year in BC is 24,951,144, suggesting the province distributed 21.5% of the units required to cover all illicit drug injections in the province.

DISCUSSION

Harm reduction product distribution is not equitable between BC HSDAs. The current level of distribution of sterile injecting equipment is inadequate to provide a clean needle for every injection.

Building on the Resilience of Aboriginal People in Risk Reduction Initiatives Targeting Sexually Transmitted Infections and Blood-Borne Viruses: The Aboriginal Community Resilience to AIDS (ACRA)

There is evidence that Aboriginal people may be at increased risk of HIV infection; they also experience higher rates of other blood-borne viral (BBV) and sexually transmitted infections (STI). This project will provide insights into the role of resilience and its impact on the health and well-being of Aboriginal youth, especially as it relates to sexual and injecting behaviour. The primary recipients of this information will be agencies that provide risk education related to BBVs and STIs.The project involves several phases. First, the framework for the research will be established, with Aboriginal leadership and involvement at every level. Next, both qualitative and quantitative methodologies will be used to identify factors that protect Aboriginal youth against blood-borne viral and sexually transmitted infections and their transmission within local communities. Finally, results from this project will be used to develop interventions and appropriate frameworks for their evaluation in Aboriginal communities.An important component of this project will involve the building of capacity within participating communities, with the goal of identifying strategies related to resilience that can be incorporated into public health and clinical practice. The project will run for five years.

Hepatitis C virus transmission among oral crack users: viral detection on crack paraphernalia

OBJECTIVE

Epidemiological studies present oral crack use as a potential independent risk factor for hepatitis C virus (HCV) status, yet actual HCV transmission pathways via crack use have not been evidenced. To this end, this exploratory study sought to detect HCV on crack-use paraphernalia used by street crack users.

METHODS

Crack-use paraphernalia within 60 min of use was collected from 51 (N) street-crack users. HCV RNA detection was conducted through eluate sampling and manual RNA extraction. Participants provided a saliva sample to test for HCV antibody, and had a digital photograph taken of their oral cavities, to assess the presence of oral sores as a possible risk factor for oral HCV transmission.

RESULTS

About 43.1% (n=22) of the study participants were HCV-antibody positive. One (2.0%) of the 51 pipes tested positive. A minority of the participants presented oral sores. The pipe on which HCV was detected was made from a glass stem; its owner was HCV-antibody positive, and there was full rater agreement on the presence of oral sores in the pipe owner's oral cavity.

CONCLUSIONS

HCV transmission from an infected host onto paraphernalia as a precondition of HCV host-to-host transmission via shared crack paraphernalia use seems possible, with oral sores and paraphernalia condition constituting possible risk modifiers. Larger-scale studies with crack users are needed to corroborate our findings.

Prevalence and associated factors of hepatitis C infection (HCV) in a multi-site Canadian population of illicit opioid and other drug users (OPICAN)

BACKGROUND

Hepatitis C virus (HCV) infection is highly prevalent in illicit drug user populations, with three in four new HCV infections related to this risk behaviour and a growing HCV disease burden in Canada. Using data from a multi-site cohort study of illicit opioid users in five Canadian cities (OPICAN), this paper explores the prevalence and predictors of HCV status in this high-risk population.

METHODS

HCV status of cohort participants was assessed by salivary antibody test. Univariate relationships of HCV status with select variables were examined on the basis of cohort baseline data, and subsequently multivariate models using logistic regression to determine independent predictors of HCV status were generated.

RESULTS

54.6% of the analysis sample (n=482) was HCV positive. Significant differences in terms of HCV prevalence existed across the sites. Significant variables in the final stepwise logistic regression model included age, site (Toronto), unprotected sex, injecting drug use, drug treatment and incarceration in past year, in addition to opioid use in combination with non-opioids.

DISCUSSION

Besides drug injecting, various other socio-behavioural factors were associated with HCV status in our cohort. On this basis, interventions focusing solely on injection risks are overly limited in scope to prevent HCV transmission in the high-risk population of illicit drug users and need to be broadened. Prevention efforts should also target young injectors as a priority.

Hepatitis C, illicit drug use and public health: does Canada really have a viable plan?

Some 300,000 individuals are infected with the hepatitis C virus (HCV) in Canada. HCV infection is associated with major morbidity, mortality and health care costs; these indicators are projected to rise over the next decade. The vast majority of prevalent and incident HCV infections in Canada are illicit drug use-related; thus, the HCV disease burden can only be addressed through interventions targeting this primary risk factor. Both preventive (e.g., needle exchange, methadone treatment) and therapeutic (e.g., the accessibility of HCV treatment for illicit drug users) interventions aimed at HCV in illicit drug users have been broadly expanded in Canada in recent years. However, evidence suggests that existing preventive measures only offer limited effectiveness in reducing HCV risk exposure. Also, due to restricted resources, treatment for HCV currently only reaches an extremely small proportion (i.e., <5%) of HCV-infected drug users. Thus, on the basis of current HCV incidence as well as given interventions and their impact, Canada is not achieving a net reduction in the prevalence of HCV-related to illicit drug use. In order to reduce the HCV disease burden, Canada needs to reconsider the scope, delivery and resourcing of both preventive and treatment interventions targeting the primary risk population of illicit drug users.

Prevalence and associated factors of hepatitis C infection (HCV) in a multi-site Canadian population of illicit opioid and other drug users (OPICAN)

BACKGROUND

Hepatitis C virus (HCV) infection is highly prevalent in illicit drug user populations, with three in four new HCV infections related to this risk behaviour and a growing HCV disease burden in Canada. Using data from a multi-site cohort study of illicit opioid users in five Canadian cities (OPICAN), this paper explores the prevalence and predictors of HCV status in this high-risk population.

METHODS

HCV status of cohort participants was assessed by salivary antibody test. Univariate relationships of HCV status with select variables were examined on the basis of cohort baseline data, and subsequently multivariate models using logistic regression to determine independent predictors of HCV status were generated.

RESULTS

54.6% of the analysis sample (n=482) was HCV positive. Significant differences in terms of HCV prevalence existed across the sites. Significant variables in the final stepwise logistic regression model included age, site (Toronto), unprotected sex, injecting drug use, drug treatment and incarceration in past year, in addition to opioid use in combination with non-opioids.

DISCUSSION

Besides drug injecting, various other socio-behavioural factors were associated with HCV status in our cohort. On this basis, interventions focusing solely on injection risks are overly limited in scope to prevent HCV transmission in the high-risk population of illicit drug users and need to be broadened. Prevention efforts should also target young injectors as a priority.

Hepatitis C, illicit drug use and public health: does Canada really have a viable plan?

Some 300,000 individuals are infected with the hepatitis C virus (HCV) in Canada. HCV infection is associated with major morbidity, mortality and health care costs; these indicators are projected to rise over the next decade. The vast majority of prevalent and incident HCV infections in Canada are illicit drug use-related; thus, the HCV disease burden can only be addressed through interventions targeting this primary risk factor. Both preventive (e.g., needle exchange, methadone treatment) and therapeutic (e.g., the accessibility of HCV treatment for illicit drug users) interventions aimed at HCV in illicit drug users have been broadly expanded in Canada in recent years. However, evidence suggests that existing preventive measures only offer limited effectiveness in reducing HCV risk exposure. Also, due to restricted resources, treatment for HCV currently only reaches an extremely small proportion (i.e., <5%) of HCV-infected drug users. Thus, on the basis of current HCV incidence as well as given interventions and their impact, Canada is not achieving a net reduction in the prevalence of HCV-related to illicit drug use. In order to reduce the HCV disease burden, Canada needs to reconsider the scope, delivery and resourcing of both preventive and treatment interventions targeting the primary risk population of illicit drug users.

Acceptabilité d’un traitement du virus de l’hépatite C chez des utilisateurs de drogues injectables au Canada

BACKGROUND

The majority of prevalent and incident hepatitis C (HCV) infections in Canada are related to injection drug use (IDU), thus positioning injection drug users (IDUs) as a critical population to be targeted for HCV treatment. Little research has been undertaken in order to discover the willingness of IDUs to receive HCV treatment, however.

METHODS

The study sample was part of the Opican (illicit OPIoid use in CANada) cohort study of illicit opioid and other drug users in five Canadian cities.

RESULTS

Data were collected from a sub-sample of 50 HCV-positive IDUs in Toronto. Four fifths of participants indicated general willingness to participate in HCV treatment. Two conditional treatment questions led to significant decreases in treatment willingness (potential treatment side effects and requirement of addiction treatment).

CONCLUSION

The majority of IDUs in this sample indicated willingness to participate in HCV treatment, yet the particular needs and situations of this marginalized population have to be considered and addressed for responsive HCV treatment delivery.

Feasibility and outcome of HCV treatment in a Canadian federal prison population

We assessed feasibility and outcome of hepatitis C virus (HCV) treatment in male correctional inmates in British Columbia, Canada. We reviewed the medical charts of 114 treated inmates; 80 had complete data for treatment outcome. Approximately 4 of 5 inmates completed treatment (78.8%); 66.3% achieved sustained virological response. Those who completed treatment, those with injection drug use as a risk factor, and those with genotypes 2 and 3 were significantly more likely to achieve sustained virological response. HCV treatment in correctional inmates is feasible and effective.

Review article: the changing epidemiology of hepatocellular carcinoma in Canada

The aim of this study was to examine the incidence of and mortality caused by hepatocellular carcinoma over the last 20 years in Canada, including the associated risk factors hepatitis C, diabetes and obesity. Databases from the Surveillance & Risk Assessment Division of Health Canada & Statistics Canada were analysed for trends in both age-adjusted incidence of and mortality due to hepatocellular carcinoma from 1984 to 2001. The epidemiological impact of hepatitis C, diabetes and obesity on hepatocellular carcinoma was also assessed. The incidence of hepatocellular carcinoma increased from 4.0 per 100,000 in 1984 to 5.5 in 2,000 for males, and from 1.6 per 100,000 in 1984 to 2.2 in 2,000 for females. Mortality rates showed a 48% increase in males and 39% increase in females. The incidence of hepatitis C increased sharply in 1995 and remained elevated until 2,000 with an average value of 85.4 per 100,000 in males and 45.4 per 100,000 in females. This increase is likely due to the widespread testing for hepatitis C. The prevalence of obesity and diabetes has increased in recent years and probably contributes to the increased incidence of hepatocellular carcinoma. The incidence of hepatocellular carcinoma in Canada has increased in the past 20 years and is associated with a rise in the incidence of hepatitis C, obesity and diabetes.

Hepatitis C treatment in a Canadian federal correctional population: Preliminary feasibility and outcomes

Hepatitis C virus (HCV) infection is a major public health concern in Canada, which now mostly affects marginalized populations, including correctional inmates. These populations ‐ until recently ‐ have largely been excluded from HCV pharmacotherapy. We report preliminary data on HCV treatment in a federal correctional population sample in British Columbia (BC), using Pegetron combination therapy. HCV RNA results are presented at week 12 of treatment, a strong predictor of treatment outcome. Just over four‐fifths (80.8%) of inmate patients had no detectable HCV RNA at week 12; inmates with genotype 2 and 3 fared better than those with genotype 1. These preliminary results suggest that HCV treatment is feasible and promises to be efficacious in correctional populations.