Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: A comprehensive approach

Socioeconomic Deprivation Weighs Heavily on Liver Fibrosis and Mortality After Hepatitis C Cure (ANRS CO22 Hepather)

Although Hepatitis C virus (HCV) infection can be cured with direct-acting antivirals (DAA), some cured patients face a serious risk of advanced liver damage and early mortality. In order to avoid these two negative health outcomes, it is important to identify and assess related risk factors. Little is currently known about socioeconomic and behavioural factors in this context. Using data from the ANRS CO22 Hepather cohort, we tested for associations between socioeconomic and behavioural factors and (i) advanced liver fibrosis (defined as an FIB-4 > 3.25) assessed longitudinally using a mixed-effects logistic regression model (both the whole population and stratified on advanced liver fibrosis status at the time of HCV cure) and (ii) all-cause mortality (Cox proportional hazards model), during post-HCV cure follow-up. Among 5833 participants cured of HCV, living in poverty was associated with postcure advanced liver fibrosis in participants without this diagnosis at the time of HCV cure (population attributable fraction-PAF-of 8.6%) and with mortality in the whole study population (PAF of 10.6%). The detrimental effects of unhealthy alcohol use and heavy tobacco smoking, as well as the beneficial effect of living with a stable partner were also highlighted. We highlighted the major role of poverty and behavioural factors in advanced liver fibrosis and all-cause mortality in patients cured of HCV. Encouraging linkage to social support services and healthy behaviours after successful DAA treatment could limit morbidity and increase survival in this population. Clinical Trial Registration: ClinicalTrials.gov: NCT01953458.

Improving healthcare for patients with HIV, tuberculosis and hepatitis C in eastern Europe: a review of current challenges and important next steps

OBJECTIVES

In some eastern European countries, serious challenges exist to meet the HIV-, tuberculosis (TB)- and hepatitis-related target of the United Nations Sustainable Development Goals. Some of the highest incidence rates for HIV and the highest proportion of multi-drug-resistant (MDR) tuberculosis worldwide are found in the region. The purpose of this article is to review the challenges and important next steps to improve healthcare for people living with TB, HIV and hepatitis C (HCV) in eastern Europe.

METHODS

References for this narrative review were identified through systematic searches of PubMed using pre-idientified key word for articles published in English from January 2000 to August 2020. After screening of titles and abstracts 37 articles were identified as relevant for this review. Thirty-eight further articles and sources were identified through searches in the authors' personal files and in Google Scholar.

RESULTS

Up to 50% of HIV/MDR-TB-coinfected individuals in the region die within 2 years of treatment initiation. Antiretroviral therapy (ART) coverage for people living with HIV (PLHIV) and the proportion virological suppressed are far below the UNAIDS 90% targets. In theory, access to various diagnostic tests and treatment of drug-resistant TB exists, but real-life data point towards inadequate testing and treatment. New treatments could provide elimination of viral HCV in high-risk populations but few countries have national programmes.

CONCLUSION

Some eastern European countries face serious challenges to achieve the sustainable development goal-related target of 3.3 by 2030, among others, to end the epidemics of AIDS and tuberculosis. Better integration of healthcare systems, standardization of health care, unrestricted substitution therapy for all people who inject drugs, widespread access to drug susceptibility testing, affordable medicines and a sufficiently sized, well-trained health workforce could address some of those challenges.

Prevalence and high risk behaviours associated with HCV testing among people who inject drugs: a systematic review and Meta-analysis

BACKGROUND

Hepatitis C diagnosis could be a gateway to behavioral change and subsequent decline in transmission among people who inject drugs (PWIDs). We assessed the association between the social determinants of PWID, their risk behaviors and hepatitis C testing.

METHODS

We searched for studies in English published before May 1, 2020, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with hepatitis C virus (HCV) testing among PWID. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. i) population: individuals who report injecting drugs; ii) intervention: HCV testing in the past year; iii) comparator: PWIDs who did not have an HCV test; iv) outcome: HCV testing among PWIDs and v) study type: cross-sectional, cohort, and case-control studies. Two independent reviewers (author BA and AB) chose the references in a two-phased monitoring process. The authors gathered data from selected papers, including the surname of the first author, publication date, participant demographic data (age, sex, and level of education) and other characteristics like previous HCV testing, past treatment attempts, duration of injecting drug use and condomless sex. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR), and 95% confidence intervals. The data were analyzed using Stata 12.0 software.

RESULTS

After a detailed assessment of over 12,000 articles, a total of 16 studies containing 38,952 participants met the eligibility criteria. Our findings showed a pooled prevalence rate of 61.01% (95% CI, 34.65-84.32%) for recent HCV testing among PWIDs. Being female (OR = 1.69, 95%CI = 1.13, 2.26), aged > 30 years, (OR = 2.61, 95%CI = 1.66-3.56) having past treatment attempt (OR = 2.24, 95%CI = 1.80-2.68), and reporting a previous test (OR = 2.03, 95%CI = 1.23-2.82). were significantly associated with having a recent HCV test.,,. Finding of present study was that unprotected sex had a negative association with HCV testing. Those PWIDs who had unprotected sex were 0.56 times less likely to have completed HCV testing during last year (OR = 0.56, 95%CI = 0.33-0.78).

CONCLUSION

Prevention programs that address age > 30 years, being female, past treatment attempt, previous testing of safe sexual practices, are strongly recommended to prioritize HCV risk reduction strategies.

Integrating HCV testing with HIV programs improves hepatitis C outcomes in people who inject drugs: A cluster-randomized trial

BACKGROUND & AIMS

There have been calls to integrate HCV testing into existing services, including harm reduction and HIV prevention and treatment, but there are few empirical trials to date. We evaluated the impact of integrating HCV testing/education into integrated care centers (ICCs) delivering HIV services to people who inject drugs (PWID) across India, using a cluster-randomized trial.

METHODS

We compared ICCs with usual care in the PWID stratum (12 sites) of a 22-site cluster-randomized trial. In 6 sites, ICCs delivering HIV testing, harm reduction, other preventive services and linkage to HIV treatment were scaled from opioid agonist therapy centers and operated for 2 years. On-site rapid HCV antibody testing was integrated after 1 year. To assess impact, we conducted baseline and evaluation surveys using respondent-driven sampling (RDS) across the 12 sites (n = 11,993 recruited at baseline; n = 11,721 recruited at evaluation). The primary outcome was population-level self-reported HCV testing history.

RESULTS

At evaluation, HCV antibody prevalence ranged from 7.2-76.6%. Across 6 ICCs, 5,263 ICC clients underwent HCV testing, of whom 2,278 were newly diagnosed. At evaluation, PWID in ICC clusters were 4-fold more likely to report being tested for HCV than in usual care clusters, adjusting for baseline testing (adjusted prevalence ratio [aPR] 3.69; 95% CI 1.34-10.2). PWID in ICC clusters were also 7-fold more likely to be aware of their HCV status (aPR 7.11; 95% CI 1.14-44.3) and significantly more likely to initiate treatment (aPR 9.86; 95% CI 1.52-63.8).

CONCLUSIONS

We provide among the first empirical data supporting the integration of HCV testing into HIV/harm reduction services. To achieve elimination targets, programs will need to scale-up such venues to deliver comprehensive HCV services. CLINICALTRIALS.

GOV IDENTIFIER

NCT01686750.

LAY SUMMARY

Delivering hepatitis C virus (HCV) testing to people who inject drugs (PWID) in places where they also have access to HIV prevention and treatment services is an effective way to improve uptake of HCV testing among communities of PWID. To achieve the World Health Organization's ambitious elimination targets, integrated programs will need to be scaled up to deliver comprehensive HCV services.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

Medical Providers and Harm Reduction Views on Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs

Despite high pre-exposure prophylaxis (PrEP) acceptability among people who inject drugs (PWID) and PrEP providers, PrEP uptake is low and little is known about how to promote PrEP among PWID. This qualitative study with providers in North Carolina explored views on PrEP delivery approaches for PWID. Interviewers conducted semistructured interviews with 10 PrEP providers and 10 harm reduction (HR) providers. Interviews were transcribed and analyzed. Many participants expressed acceptability for providing PrEP referrals at syringe exchange sites, stationing PrEP providers at syringe exchange sites to provide PrEP prescriptions, and providing standing orders for PrEP at syringe exchange sites. Barriers were identified, including low PrEP awareness and limited resources. Many advocated for co-location of HR and PrEP services and scaled-up outreach services. PrEP providers emphasized maintenance of clinical requirements, while HR providers emphasized flexibility when treating PWID. Promoting PrEP uptake and adherence among PWID likely requires integration of HR and PrEP services.

Associating conditional cash transfer to universal access to treatment could be the solution to the HCV epidemic among drug users (DUs)

Background

To understand the limits of HCV screening programs to reach all drug users (DUs).

Method

The association of the recruitment of a representative sample of a population of DUs in a specific area with the use of a questionnaire that included 250 items allowed the use of uni- and multifactorial analysis to explore the relationship between HCV screening and dimensions until now restricted to qualitative studies.

Results

We recruited, in less than 2 months, 327 DUs representing about 6% of the total population of DUs. They belonged to a single community whose drug use was the only common characteristic. While almost all DUs (92.6%) who had access to care providers had been screened, this proportion was much lower in out-of-care settings (64%). HCV prevalence among those who had performed a test was low (22.8%). For DUs, the life experience of hepatitis C has not changed in the last 10 years. Screening, studied for the first time according to this life experience, was not influenced by a rational knowledge of the risk taken or the knowledge of treatment efficacy, showing a gap between DUs’ representations and medical recommendations which explains the low level of active screening. Police crackdown on injections, disrupting the previous illusion of safe practices, was the only prior history leading to active screenings. Screenings were related to an access to care providers. GPs held a preponderant position as a source of information and care by being able to give appropriate answers regarding hepatitis C and prescribing opioid substitution treatments (OST). If 48 % of DUs screened positive for HCV had been treated, half of them had been prescribed before 2006.

Conclusion

While hepatitis has become a major issue for society and, consequently, for services for DUs (SDUs) and GPs, it is not the case for DUs. A widespread screening, even in a city where the offer of care is diversified and free, seems unlikely to reach a universal HCV screening over a short time. The model of respondent-driven sampling recruitment could be a new approach to conditional cash transfer, recruiting and treating DUs who remain outside the reach of care providers, a prerequisite for the universal access to HCV treatments to impact the HCV epidemic.

Economically Efficient Hepatitis C Virus Treatment Prioritization Improves Health Outcomes

BACKGROUND

The total cost of treating the 3 million Americans chronically infected with hepatitis C virus (HCV) represents a substantial affordability challenge requiring treatment prioritization. This study compares the health and economic outcomes of alternative treatment prioritization schedules.

METHODS

We developed a multiyear HCV treatment budget allocation model to evaluate the tradeoffs of 7 prioritization strategies. We used optimization to identify the priority schedule that maximizes population net monetary benefit (NMB). We compared prioritization schedules in terms of the number of individuals treated, the number of individuals who progress to end-stage liver disease (ESLD), and population total quality-adjusted life years (QALYs). We applied the model to the population of treatment-naive patients with a total annual HCV treatment budget of US$8.6 billion.

RESULTS

First-come, first-served (FCFS) treats the fewest people with advanced fibrosis, prevents the fewest cases of ESLD, and gains the fewest QALYs. A schedule developed from optimizing population NMB prioritizes treatment in the first year to patients with moderate to severe fibrosis who are younger than 65 years, followed by older individuals with moderate to severe fibrosis. While this strategy yields the greatest population QALYs, prioritization by disease severity alone prevents more cases of ESLD. Sensitivity analysis indicated that the differences between prioritization schedules are greater when the budget is smaller. A 10% annual treatment price reduction enabled treatment 1 year sooner to several patient subgroups, specifically older patients and those with less severe liver fibrosis.

CONCLUSION

In the absence of a sufficient budget to treat all patients, explicit prioritization targeting younger people with more severe disease first provides the greatest health benefits. We provide our spreadsheet model so that decision makers can compare health tradeoffs of different budget levels and various prioritization strategies with inputs tailored to their population.

Liver Disease Monitoring Practices After Hepatitis C Cure in the Underserved Population

Recent hepatitis C virus (HCV) guidelines recommend disease monitoring and hepatocellular carcinoma (HCC) screening in patients with advanced fibrosis after a sustained virologic response (SVR) with direct-acting antiviral (DAA) therapy. However, data on practice patterns in this setting is lacking. We aimed to characterize disease monitoring and HCC screening practices post-SVR in an underserved HCV-infected cohort. Records of 192 patients who received DAA therapy at the San Francisco safety-net health care system between January 2014 and January 2016 with ≥12 months of follow-up post-SVR were reviewed. Patient characteristics were median age 58 years, 61.5% men, 39.1% White (23.4% Black, 16.7% Latino, 16.2% Asian), 78.1% English proficient, 48.9% intravenous drug use, 53.2% alcohol use, and 41% advanced (F3 and F4) fibrosis (26.6% with decompensation, 11.4% with HCC). Median post-SVR follow-up time was 22 months. A higher proportion of patients with advanced fibrosis attended liver clinic visits (mean, 1.94 ± 2.03 versus 1.12 ± 1.09 visits; P = 0.014) and had liver imaging (41.4% versus 9.73%; P < 0.001) post-SVR, but there was no difference in alanine aminotransferase (ALT) testing (72.2% versus 66.4%; P = 0.40) compared to those without advanced fibrosis. However, 20% with advanced fibrosis had no HCC screening while 35% with no advanced fibrosis had liver imaging. Three patients with cirrhosis developed new HCC. Conclusion: Although the majority of patients with advanced fibrosis in this underserved cohort received post-SVR monitoring, gaps in HCC screening were identified and new cases of HCC occurred during a short follow-up. This highlights the importance of incorporating recently enhanced guidelines to optimize post-SVR monitoring, especially in difficult to engage populations.

Hepatitis C virus prevention and care for drug injectors: the French approach

After France removed hepatitis C treatment reimbursement restrictions on 25 May 2016, an expert report presented recommendations, which focused on vulnerable groups including people who inject drugs (PWID). This commentary presents the key points of the chapter with a particular focus on policy. Thanks to the official lifting of restrictions based on disease stage and to the excellent efficacy and tolerance of the new DAA (Direct-Acting Antivirals) among PWID, the main issue is to improve the HCV care cascade. In France, many HCV-infected PWID, especially active/current PWID, remain undiagnosed and unlinked to care. Our challenge is to improve HCV screening by point of care testing (POCT), outreach methods with mobile teams, rapid tests, FibroScan, etc. and to provide PWID with appropriate services in all the settings they attend, such as drug treatment or harm reduction services, social services, prisons, etc. Another important issue is the prevention of reinfection through comprehensive and long-term follow-up. The report recommends a new national policy: testing and treating PWID as a priority, since this is the best way to eliminate HCV infection. It requires a global strategy consisting of combined and long-term interventions: prevention, outreach, screening, DAA, drug treatment programs including opiate substitution treatment (OST) and various harm reduction programs, including needle exchange programs (NEP). Ideally, these services should be delivered in the same place with an integrated approach. This should lead to meeting the national objective set by the government of eliminating hepatitis C by 2025.

Hepatitis C infection, related services, and barriers to HCV treatment among drug users in methadone maintenance treatment (MMT) clinics in Shanghai, China

Background

The purpose of this study was to document the prevalence of hepatitis C among MMT patients, hepatitis C virus (HCV) knowledge of patients and MMT staff members, and the barriers preventing them from receiving or delivering HCV-related services in MMT clinics of China.

Methods

Data were collected from 240 MMT patients and 58 staff members in Shanghai MMT clinics. Structured questionnaires (HCV Knowledge Scale and Alcohol Use Disorders Identification Test) and several self-developed questionnaires were used to assess (1) patient and staff HCV knowledge, (2) attitudes toward HCV-related services in MMT clinics, and (3) what type of HCV-related services the staff members have provided in their routine work. The HCV test results were based on the patients’ medical records.

Results

The HCV seropositive rate was high (70%), and both patients and staff had limited HCV knowledge. The mean score of patient HCV knowledge was 6.8 out of 20 (SD = 3.7), whereas the mean score of staff HCV knowledge was 10.9 out of 20 (SD = 3.1). For HCV-positive patients, only 13.7% had accessed HCV medical treatment. Barriers included the cost of medical treatment, lack of HCV knowledge, lack of professional training for patients to receive HCV-related services from individuals or MMT clinics, and lack of an adequate policy-making system.

Conclusions

HCV infection remains an important problem among MMT patients in China. Barriers to HCV-related services are attributable to individual, clinical, and policy-related factors. This study may provide evidence-based information for future work to optimize the resources of MMT clinics.

Trial registration

ClinicalTrials.gov NCT01647191. Registered 17 April 2012.

Healthcare contact and treatment uptake following hepatitis C virus screening and counseling among rural Appalachian people who use drugs

BACKGROUND

Hepatitis C virus (HCV) remains a major contributor to morbidity and mortality worldwide. Since 2009, Kentucky has led the United States in cases of acute HCV, driven largely by injection drug use in rural areas. Improved treatment regimens hold promise of mitigating the impact and transmission of HCV, but numerous barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved settings.

METHODS

503 rural people who use drugs were recruited using respondent-driven sampling and received HCV screening and post-test counseling. Presence of HCV antibodies was assessed using enzyme immunoassay of dried blood samples. Sociodemographic and behavioral data were collected using computer-based questionnaires. Predictors of contacting a healthcare provider for follow-up following HCV-positive serotest and counseling were determined using discrete-time survival analysis.

RESULTS

150 (59%) of 254 participants reported contacting a healthcare provider within 18 months of positive serotest and counseling; the highest probability occurred within six months of serotesting. 35 participants (14%) reported they were seeking treatment, and 21 (8%) reported receiving treatment. In multivariate time-dependent modeling, health insurance, internet access, prior substance use treatment, meeting DSM-IV criteria for generalized anxiety disorder, and recent marijuana use increased the odds of making contact for follow-up. Participants meeting criteria for major depressive disorder and reporting prior methadone use, whether legal or illegal, were less likely to contact a provider.

CONCLUSION

While only 8% received treatment after HCV-positive screening, contacting a healthcare provider was frequent in this sample of rural PWID, suggesting that the major barriers to care are likely further downstream. These findings offer insight into the determinants of engaging the cascade of medical treatment for HCV and ultimately, treatment-as-prevention. Further study and increased resources to support integrated interventions with effectiveness in other settings are recommended to mitigate the impact of HCV in this resource-deprived setting.

Project P.E.A.C.H. (Pathway and Education Toward Adherence and Completion in Hepatitis C Therapy): A Nurse-Driven Evidence-Based Protocol

Chronic hepatitis C virus (HCV) remains a major healthcare concern. The 24-48 week treatment of pegylated interferon and ribavirin therapy requires a tremendous amount of commitment from patients and providers. Thus, there has been a huge focus on health-related quality of life and various measures to support patient adherence and completion of the recommended HCV treatment regimen. This quality improvement project aimed to develop and test a nurse-driven evidence-based pathway that supports the care of patients receiving hepatitis C medication therapy in a tertiary, academic hepatology practice. All adult patients, 18 years and older, who were started on HCV treatment from January 20 to February 15, 2011, were included in the testing of a nurse-driven HCV pathway for the first 12 weeks of treatment. The majority of the patients treated were male (71.8% prepathway and 83.3% postpathway), of White ethnic background (61.5% prepathway and 58.3% postpathway), genotype 1 (69% prepathway and 91.7% postpathway), and had comorbid conditions classified as "other" (38.5% prepathway and 33.3% postpathway). As for treatment status, the majority of the patients were "treatment naive" in prepathway or had never received prior HCV treatment (59.0%) or "had recurrent HCV after liver transplantation" (41.7%). The 4-week treatment completion rate was 94.9% for the prepathway group and 100.0% for the postpathway group; 12-week completion rate was 87.2% (prepathway) and 58.3% for the postpathway group. The mean 4-week adherence score for the prepathway group was 2.46 and the postpathway group was 2.92. Mean lag time to treatment was decreased with 26 days in the postpathway and 43 in the prepathway. Providers and nurses expressed overall satisfaction with the nurse-driven pathway.

A multidimensional education program at substance dependence treatment centers improves patient knowledge and hepatitis C care

Background

HCV treatment among people who inject drugs (PWID) is low. Education programs may be suitable strategies to improve patients’ knowledge about their condition and to overcome barriers to access treatment.

Methods

The Health Educational Program (HEP) consisted of patient workshops and educational videos and leaflets, and healthcare professionals’ workshops. HEP was implemented at seven substance dependence treatment centers (STDC) in Portugal. The study comprised two cross-sectional evaluations conducted before and after HEP. At both evaluations, adult patients with confirmed HCV diagnosis and registered in the STDC were consecutively included. For patients that completed both evaluations, the overall knowledge score were calculated and compared with McNemar test. Linear regression modelling was used to evaluate factors associated with baseline knowledge. Rates of referral and attendance to referral specialist, treatment proposal, initiation and retention at both evaluations were also compared with McNemar test.

Results

Overall, 504 patients with chronic hepatitis C were included: 78 % male, mean age 42.3 ± 6.6 years, 14 % school education ≤ 4 years, disease duration 11.0 ± 6.0 years and 26 % HIV co-infected. A higher baseline knowledge was independently associated with educational level ≥ 10 years (regression coefficient [B] =15.13, p < 0.001), current use of intravenous drugs (B = 7.99, p = 0.038), previous referral for treatment (B = 4.26, p = 0.008) and previous HCV treatment (B = 5.40, p = 0.003). Following HEP, mean knowledge score increased from 69 % to 79 % (p < 0.001). The rate of patient referral to a liver specialist increased from 56.2 % to 67.5 % (p < 0.001).

Conclusions

An HEP conducted at STDCs improved significantly patient knowledge about hepatitis C, even among patients with a high baseline knowledge. The HEP has also increased the rate of referral to the liver specialist and showed a great potential to support healthcare professionals in managing HCV. Education programs may promote treatment access among PWID, a population that represents the majority of HCV infected patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1883-6) contains supplementary material, which is available to authorized users.

Harm Reduction: Front Line Public Health

Drug use is a public health problem associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care. Harm reduction is a pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life. Harm reduction prioritizes improving the lives of people who use drugs in partnership with those served without a narrow focus on abstinence from drugs. Evidence has shown that harm reduction oriented practice can reduce transmission of blood-borne illnesses, and other injection related infections, as well as preventing fatal overdose.

Hepatitis C testing in substance use disorder treatment: the role of program managers in adoption of testing services

BACKGROUND

Health care organizations do not adopt best practices as often or quickly as they merit. This gap in the integration of best practices into routine practice remains a significant public health concern. The role of program managers in the adoption of best practices has seldom been investigated.

METHODS

We investigated the association between characteristics of program managers and the adoption of hepatitis C virus (HCV) testing services in opioid treatment programs (OTPs). Data came from the 2005 (n = 187) and 2011 (n = 196) National Drug Abuse Treatment System Survey (NDATSS). We used multivariate regression models to examine correlates of the adoption of HCV testing. We included covariates describing program manager characteristics, such as their race/ethnicity, education, and their sources of information about developments in the field of substance use disorder treatment. We also controlled for characteristics of OTPs and the client populations they serve.

RESULTS

Program managers were predominantly white and female. A large proportion of program managers had post-graduate education. Program managers expressed strong support for preventive services, but they reported making limited use of available sources of information about developments in the field of substance use disorder (SUD) treatment. The provision of any HCV testing (either on-site or off-site) in OTPs was positively associated with the extent to which a program manager was supportive of preventive services. Among OTPs offering any HCV testing to their clients, on-site HCV testing was more common among programs with an African American manager. It was also more common when program managers relied on a variety of information sources about developments in SUD treatment.

CONCLUSIONS

Various characteristics of program managers are associated with the adoption of HCV testing in OTPs. Promoting diversity among program managers, and increasing managers' access to information about developments in SUD treatment, may help foster the adoption of best practices.

Self-Reported HIV and HCV Screening Rates and Serostatus Among Substance Abuse Treatment Patients

Substance users are at increased risk for HIV and HCV infection. Still, many substance use treatment programs (SUTP) fail to offer HIV/HCV testing. The present secondary analysis of screening data from a multi-site randomized trial of rapid HIV testing examines self-reported HIV/HCV testing patterns and serostatus of 2473 SUTP patients in 12 community-based sites that had not previously offered on-site testing. Results indicate that most respondents screened for the randomized trial tested more than a year prior to intake for HIV (52 %) and HCV (38 %). Prevalence rates were 3.6 and 30 % for HIV and HCV, respectively. The majority of participants that were HIV (52.2 %) and HCV-positive (40.5 %) reported having been diagnosed within the last 1-5 years. Multivariable logistic regression showed that members of high-risk groups were more likely to have tested. Bundled HIV/HCV testing and linkage to care issues are recommended for expanding testing in community-based SUTP settings.

Insufficient access to harm reduction measures in prisons in 5 countries (PRIDE Europe): a shared European public health concern

Background

Prisoners constitute a high-risk population, particularly for infectious diseases. The aim of this study was to estimate the level of infectious risk in the prisons of five different European countries by measuring to what extent the prison system adheres to WHO/UNODC recommendations.

Methods

Following the methodology used in a previous French survey, a postal/electronic questionnaire was sent to all prisons in Austria, Belgium, Denmark and Italy to collect data on the availability of several recommended HIV-HCV prevention interventions and HBV vaccination for prisoners. A score was built to compare adherence to WHO/UNODC recommendations (considered a proxy of environmental infectious risk) in those 4 countries. It ranged from 0 (no adherence) to 12 (full adherence). A second score (0 to 9) was built to include data from a previous French survey, thereby creating a 5-country comparison.

Results

A majority of prisons answered in Austria (100 %), France (66 %) and Denmark (58 %), half in Belgium (50 %) and few in Italy (17 %), representing 100, 74, 89, 47 and 23 % coverage of the prison populations, respectively. Availability of prevention measures was low, with median adherence scores ranging from 3.5 to 4.5 at the national level. These results were confirmed when using the second score which included France in the inter-country comparison. Overall, the adherence score was inversely associated with prison overpopulation rates (p = 0.08).

Conclusions

Using a score of adherence to WHO/UNODC recommendations, the estimated environmental infectious risk remains extremely high in the prisons of the 5 European countries assessed. Public health strategies should be adjusted to comply with the principle of equivalence of care and prevention with the general community.

A window of opportunity: maximizing the effectiveness of new HCV regimens in the United States with the expansion of the Affordable Care Act

Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management. New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.

A comprehensive hepatitis C virus risk factors meta-analysis (1989-2013): do they differ in Egypt?

BACKGROUND & AIMS

The prevention and control of HCV infection is complex and challenging in terms of describing risk factors and modes of transmission. This meta-analysis was conducted to summarize the best available data on HCV risk factors worldwide and in Egypt.

METHODS

Through exhaustive literature searches (1989-2013) of HCV risk factors, 357 original eligible articles were included in this study.

RESULTS

The highest detected risk was intravenous drug users (IDUs) (OR = 9.6) followed by HIV infection (OR = 4.9), having an IDU partner (OR = 4.1), HBV infection (OR = 3.5), Caesarean section (CS) (OR = 3.35), blood transfusion (OR = 3.2) and having an HCV+ partner (OR = 3). Organ transplantation, hospital admission, haemodialysis and having a sexually transmitted infection carry 2.96, 2.4, 2.18 and 2 risks of having HCV respectively. Other significant risk factors included poor education, older age, sharing sharp or blunt objects, MSM, tattooing, hijama, body piercing, minor operations and medical procedures. Some risks showed a decrease over the previous decade, including blood transfusion, organ transplantation, IDUs, IDU partner and CS. Others showed rising risks, including having an HCV+ partner, MSM and suffering from STI. In Egypt, male gender, rural residence, acupuncture and receiving parenteral antischistosomal treatment were significant risks, while neither HIV nor HBV were found to carry a risk of HCV infection.

CONCLUSION

Blood transfusion, organ transplantation, CS, IDUs, haemodialysis, minor operations and medical procedures are established risk factors. Attention and urgent intervention should be given to the sexual route of transmission, as well as that through minor operations and medical procedures.

Increasing hepatitis C knowledge among homeless adults: results of a community-based, interdisciplinary intervention

Homeless adults have high rates of hepatitis C virus infection (HCV) and low levels of HCV knowledge. This study reports results of an interdisciplinary, community-based intervention using stakeholder cooperation, case management, risk factor identification, and modification of dysfunctional psychosocial factors to increase HCV knowledge among homeless adults (N = 747). Data are from a randomized quasi-experimental study, with the major goal of evaluating the effectiveness of a Nurse Case Managed Intervention compared to a Standard Intervention, encouraging completion of a three-series hepatitis A/hepatitis B vaccination program. Increased HCV knowledge was measured with an 18-item questionnaire discerning risk factors for HCV and common misconceptions about individuals with HCV. A significant increase in HCV knowledge resulted regardless of intervention format. Receiving the Nurse Case Managed Intervention predicted greatest gain in HCV knowledge (p < 0.000). Successfully engaging key stakeholders, outreach workers, community organizations, and homeless people themselves proved most efficacious in increasing HCV knowledge.

Feasibility of providing interventions for injection drug users in pharmacy settings: a case study among San Francisco pharmacists

In addition to syringe exchange programs, pharmacies are important venues where injection drug users (IDUs) can access non-prescription syringes and other prevention interventions. This study assessed the feasibility of providing a range of interventions for IDUs in pharmacy settings. Semi-structured qualitative interviews were conducted with 23 participants (policy makers, owner/managers, dispensing pharmacists, and pharmacy staff) from independent and chain/retail pharmacies in San Francisco, California, USA. The highest level of support was for a coupon syringe program and educational materials. Several overarching themes illustrate challenges to implementing pharmacy-based preventive interventions: time, space, sufficient staff, pharmacist training, legal considerations, pharmacist attitudes toward IDUs, and cost and reimbursement issues. This study provides concrete examples of the types of preventive services that pharmacists support and consider feasible, and illustrates that pharmacists welcome the opportunity to broaden their role as critical partners in public health matters related to injection drug use.

Can hepatitis C be eradicated in the United States?

The advent of highly effective antiviral regimens will make the eradication of hepatitis C in high-income countries such as the United States technically feasible. But eradicating hepatitis C will require escalating our response to the epidemic in key domains, including surveillance and epidemiology, prevention, screening, care and treatment, policy, research, and advocacy. Surveillance must be nimble enough to quickly assess the magnitude of new transmission patterns as they emerge. Basic prevention strategies - community-based outreach and education, testing and counseling, and access to sterile injection equipment and opioid substitution therapies - must be scaled up and adapted to target groups in which new epidemics are emerging. All adults should be screened for hepatitis C, but special efforts must focus on groups with increased prevalence through community outreach and rapid testing. Government, industry, and payers must work together to assure full access to health services and antiviral drugs for everyone who is infected. Access to the new regimens must not be compromised by excessively high prices or arbitrary payer restrictions. Partnerships must be forged between hepatitis providers and programs that serve people who inject illicit drugs. Healthcare providers and systems, especially primary care practitioners, need education and training in treating hepatitis C and caring for substance-using populations. Services must be provided to the disadvantaged and stigmatized members of society who bear a disproportionate burden of the epidemic. Environments must be created where people who use drugs can receive prevention and treatment services without shame or stigma. Action is needed to end the policy of mass incarceration of people who use drugs, reduce the stigma associated with substance use, support the human rights of people who use drugs, expand social safety net services for the poor and the homeless, remove the legal barriers to hepatitis C prevention, and build public health infrastructure to reach, engage, and serve marginalized populations. Governments must take action to bring about these changes. Public health agencies must work with penal institutions to provide prevention and treatment services, including antiviral therapy, to those in need in jails and prisons or on probation or parole. Research is needed to guide efforts in each of these domains. Strong and sustained political advocacy will be needed to build and sustain support for these measures. Leadership must be provided by physicians, scientists, and the public health community in partnership with community advocates and people living with or at risk for hepatitis C. Eliminating hepatitis C from the United States is possible, but will require a sustained national commitment to reach, test, treat, cure, and prevent every case. With strong political leadership, societal commitment, and community support, hepatitis C can be eradicated in the United States. If this is to happen in our lifetimes, the time for action is now. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication."

Determinants of the availability of hepatitis C testing services in opioid treatment programs: results from a national study

OBJECTIVES

We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs.

METHODS

We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability.

RESULTS

Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios.

CONCLUSIONS

The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.

Integrating health and prevention services in syringe access programs: a strategy to address unmet needs in a high-risk population

Injection drug users are at a high risk for a number of preventable diseases and complications of drug use. This article describes the implementation of a nurse-led health promotion and disease prevention program in New Jersey's syringe access programs. Initially designed to target women as part of a strategy to decrease missed opportunities for perinatal HIV prevention, the program expanded by integrating existing programs and funding streams available through the state health department. The program now offers health and prevention services to both men and women, with 3,488 client visits in 2011. These services extend the reach of state health department programs, such as adult vaccination and hepatitis and tuberculosis screening, which clients would have had to seek out at multiple venues. The integration of prevention, treatment, and health promotion services in syringe access programs reaches a vulnerable and underserved population who otherwise may receive only urgent and episodic care.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless

Background

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted.

Methods

We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion.

Results

Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3–14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04).

Conclusions

Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009–2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Adherence and completion in hepatitis C management: a systematic review

The complexity and challenge of Hepatitis C virus (HCV) medication therapy call for a comprehensive and integrated approach in management. This article includes an appraisal of the current state of the science in HCV management and the various models that support treatment completion and adherence. The patient undergoing HCV therapy may experience a wide range of symptoms such as anemia, depression, fatigue, and flu-like symptoms. These can constantly confront the patient's adherence and compliance with treatment. The article includes an analysis of the strengths, weaknesses, and limitations of the evidence. Future directions in research were also identified.

Hepatitis-C multimedia prevention program in poor Hispanic HIV-infected injecting drug users: six months after intervention

BACKGROUND

In order to prevent the spread of the hepatitis C virus (HCV) amongst Hispanic injection drug users (IDUs), we developed, validated, and implemented a multimedia educational intervention program.

METHODS

A pre-post intervention study design was used to evaluate long-lasting knowledge and behavior changes in a group of 88 low-income Hispanic HIV-infected IDUs. Pre-intervention data was compared with data measured six months after the intervention.

RESULTS

A significant increase in the awareness regarding HCV clinical manifestations, HCV risky behaviors, HCV prevention practices, and HIV/HCV co-infection synergisms was observed in the group six months post-intervention.

CONCLUSION

Our study confirms the long-lasting benefits of multimedia based intervention programs for disseminating HCV prevention strategies in IDUs. Preventive educational approaches that use images, figures, and animations tools can be recommended to target and tailor interventions for vulnerable populations.

Seroprevalence of HIV, hepatitis B virus, and HCV among injection drug users in Connecticut: understanding infection and coinfection risks in a nonurban population

OBJECTIVES

We examined HIV, hepatitis B virus (HBV), and HCV seroprevalence in an interim analysis and the potential risk factors associated with these infections among injection drug users (IDUs) residing in nonurban communities of southwestern Connecticut.

METHODS

We recruited and interviewed active adult IDUs about their injection-associated risk and conducted serological tests for HIV, HBV, and HCV. Regression analyses were performed to identify risk factors for infection and coinfection.

RESULTS

Among 446 participants, 51.6% carried at least 1 infection, and 16.3% were coinfected. Infection risk was associated with longer duration of injection use, overdose, substance abuse treatment, depression, and involvement with the criminal justice system. Coinfection was associated with longer injection drug use, lower education, overdose, and criminal justice involvement. Multivariate models identified injection drug use duration, substance abuse treatment, and criminal justice involvement as the most significant predictors of infection; injection drug use duration and education were the most significant predictors of coinfection.

CONCLUSIONS

Suburban IDUs are at significant risk for acquiring single and multiple viral infections. Effective harm reduction strategies are needed to reach users early. There might be roles for interventions in the treatment and justice systems in which IDUs interact.

Low rates of hepatitis C testing among people who inject drugs in Thailand: implications for peer-based interventions

BACKGROUND

Regular testing for hepatitis C virus (HCV) provides an opportunity for HCV prevention and treatment efforts. In Thailand, the barriers and facilitators of HCV testing among people who inject drugs (IDU) are not known.

METHODS

Using data derived from the Mitsampan Community Research Project between July and October 2011, we assessed the prevalence and factors associated with ever having been tested for HCV antibodies using bivariate statistics and multivariate logistic regression.

RESULTS

Among 427 participants, 141 (33.0%) reported a history of HCV antibody testing. In multivariate analyses, factors positively associated with receiving an HCV antibody test included higher than secondary education [adjusted odds ratio (AOR) = 2.20; 95% confidence interval (CI): 1.35-3.64], binge drug use (AOR = 1.81; 95% CI: 1.12-2.93), methadone treatment enrollment (AOR = 3.47; 95% CI: 1.85-6.95) and having received peer-based education on HCV (AOR = 4.22; 95% CI: 2.66-6.77).

CONCLUSIONS

We found one-third of Thai IDU in our sample reporting a history of HCV testing. The finding that IDU who received peer-based HCV education were more likely to access HCV testing provides evidence for the value of peer-based interventions for this population.

10-year trends in the diagnosis and treatment of hepatitis C and concomitant mental health disorders: 1995 to 2005

OBJECTIVE

To evaluate trends in the rate and timing of treatment for hepatitis C in those with and without mental health comorbidities.

METHOD

Data from the population-based Olmsted County Hepatitis C Registry in Minnesota were linked to patients' medical records to identify the dates and duration of any hepatitis C-specific therapy as well as all diagnoses of mental health comorbid conditions prior to initiation of therapy. The most common mental health conditions, major depressive disorder, alcohol dependence, and intravenous drug use, were assessed separately. The registry includes all Olmsted County residents with a physician diagnosis of hepatitis C or non-A/non-B hepatitis (ICD-9 criteria) from January 1, 1990, through December 31, 2005.

RESULTS

The age-adjusted prevalence of diagnosed hepatitis C increased markedly between 1995 and 2000 (15.5/10,000 persons to 27.0/10,000 persons) but changed little between 2000 and 2005 (27.0 to 27.9/10,000 persons). The number of people with comorbid hepatitis C and depressive disorder (including minor depression) increased significantly between 1995 and 2005 from 18% to over 35% of all people with diagnosed hepatitis C. Treatment rates more than doubled between 1995 and 2005, while the time from diagnosis to treatment decreased during that same period. By 2005, major depressive disorders were associated with a high rate of reasonably prompt treatment. There were no gender differences in treatment rates or time to treatment when other comorbidities and age were included in the analyses.

CONCLUSIONS

From 1995 to 2005, rates of treatment for hepatitis C among people with and without comorbid mental health problems increased. Rates of increase were higher among those with depression and hepatitis C than among those with hepatitis C and drug abuse or other mental health diagnoses. Even with this progress in treating those with multiple diagnoses, over 75% of people with hepatitis C remain untreated.

Pharmacy staff characteristics associated with support for pharmacy-based HIV testing

OBJECTIVES

To determine support of in-pharmacy human immunodeficiency virus (HIV) testing among pharmacy staff and the individual-level characteristics associated with in-pharmacy HIV testing support.

DESIGN

Descriptive, nonexperimental, cross-sectional study.

SETTING

New York City (NYC) from January 2008 to March 2009.

PARTICIPANTS

480 pharmacy staff, including pharmacists, owners/managers, and technicians/clerks.

INTERVENTION

131 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey.

MAIN OUTCOME MEASURE

Support of in-pharmacy HIV testing.

RESULTS

Support of in-pharmacy HIV testing is high among pharmacy staff (79.4%). Pharmacy staff who supported in-pharmacy vaccinations were significantly more likely to support in-pharmacy HIV testing. Pharmacy staff who thought that selling syringes to injection drug users (IDUs) caused the community to be littered with dirty syringes were significantly less likely to support in-pharmacy HIV testing.

CONCLUSION

Support for in-pharmacy HIV testing was high among our sample of ESAP pharmacy staff actively involved in nonprescription syringe sales. These findings suggest that active ESAP pharmacy staff may be amenable to providing HIV counseling and testing to IDUs and warrants further investigation.

Saúde pública, redução de danos e a prevenção das infecções de transmissão sexual e sanguínea: revisão dos principais conceitos e sua implementação no Brasil

Este artigo aborda o contexto histórico e o marco conceitual da implantação dos programas de redução de danos no campo da saúde pública, com ênfase nos programas brasileiros. A presente revisão teve como objetivo principal investigar a pertinência atual de tais programas no enfrentamento das infecções de transmissão sexual e sanguínea, em especial, a AIDS e a hepatite C. Os resultados sistematizados pela literatura nacional e internacional indicam que as ações práticas de redução de danos são mais efetivas quando integradas a outras medidas de saúde pública, guiadas por princípios em comum. Iniciativas de redução de danos afinadas com princípios de saúde pública não se prendem a modelos, nem se esgotam em cuidados de saúde propriamente ditos. Abrangem diversas modalidades de ações pragmáticas, com base em políticas públicas, devem estar em sintonia com a comunidade desde seu planejamento, e serem executadas em parceria com esta.

A randomized controlled trial of an integrated care intervention to increase eligibility for chronic hepatitis C treatment

OBJECTIVES

Mental health and substance abuse (MH/SA) comorbidities are the most oft-cited reasons for deferral from peginterferon (PegIFN) therapy for chronic hepatitis C virus (HCV). We sought to determine whether an integrated care intervention (INT) for patients deferred from PegIFN owing to MH/SA could improve subsequent treatment eligibility rates.

METHODS

In this randomized controlled trial, 101 HCV patients who were evaluated at two hepatology centers and deferred from antiviral therapy owing to MH/SA were enrolled. Participants were randomized to an INT (N=50) or standard of care (SC; N=51). The INT group received counseling and case management for up to 9 months. All participants underwent 3-, 6-, and 9-month clinical follow-up visits, where hepatologists, masked to group, re-evaluated patients for treatment eligibility. Standardized mood and alcohol use instruments were administered to all participants to aid clinicians in treatment decisions.

RESULTS

Of 101 participants, the mean age was 48 years and 50% were men, 61% Caucasian, and 77% genotype 1. Patients were initially deferred owing to psychiatric issues (35%), alcohol abuse (31%), drug abuse (9%), or more than one of these reasons (26%). In an intent-to-treat analysis, 42% (21/50) of INT participants became eligible for therapy compared to 18% (9/51) of SC participants (P=0.009, relative risk (RR)=2.38, 95% confidence interval (CI) (1.21, 4.68)). When baseline predictors significant at P<0.10 in univariate models were entered into multivariate models adjusted for treatment group, only baseline depression remained significant (P=0.05, RR=0.98, 95% CI (0.96, 1.00)). With the exception of a model adjusted for genotype, treatment group remained significant in all models.

CONCLUSIONS

This trial suggests that INTs can increase eligibility for HCV treatment and expand treatment to the underserved population with MH/SA comorbidities.

Addressing the HIV-related needs of substance misusers in New York State: the benefits and barriers to implementing a "one-stop shopping" model

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs) are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

Notions of Injecting Drug Users' Candidacy for Hepatitis C Treatment: Conflicting Provider, Patient, and Public Health Perspectives

Uptake of hepatitis C treatment by injecting drug users (IDUs) remains low and little is known about factors influencing treatment uptake by ethnic minority groups. The influence of notions of “candidacy” on “accomplishing” access to antiviral treatment are explored using data from an ethnographic study. Fieldwork and in-depth interviews were conducted with 72 Indo-Chinese IDUs. Cultural contexts, everyday realities of drug use and marginalization, and disengagement from the health system produced notions of candidacy in participants' local worlds. Among the minority assessed for treatment, adjudications of candidacy were perceived to be influenced by power dynamics. Demonstrating abstinence from drug use was understood to be central to establishing legitimate claims for candidacy, suggesting conflicting provider, patient, and public health perspectives. Further research is needed to identify drivers of institutional notions of candidacy and determine ways to ensure these do not produce discriminatory practices and policies that exclude and disadvantage particular groups.

Access to sterile syringes through San Francisco pharmacies and the association with HIV risk behavior among injection drug users

Increased options for syringe acquisition and disposal have been associated with reductions in high-risk behaviors. This study determined the extent of pharmacy uptake in accessing syringes among injection drug users (IDUs) and estimated associations between pharmacy uptake and safer injection/disposal practices. Two years after the implementation of California's Disease Prevention Demonstration Project, which removed restrictions to non-prescription syringe sales through pharmacies with local authorization, IDUs were recruited through street outreach in San Francisco and interviewed regarding recent syringe acquisition, use, and disposal. The sample of 105 persons included a high proportion of men (67%), people of color (49%), and homeless persons (71%). The most common syringe source was a syringe exchange program (SEP) (80%), with pharmacies being accessed by 39% of respondents. The most commonly cited source of disposal was a SEP (65%), with very few reports of pharmacy disposal (2%). Adjusted analysis showed that unsuccessful attempts to purchase syringes at a pharmacy increased the odds of both injecting with a used syringe and giving away a used syringe. Using a SEP decreased the odds of unsafe injection and disposal practices. Thus, 2 years after the initiation of the California Disease Prevention Demonstration Project, results from this small study suggest that SEPs still provide the majority of syringe distribution and disposal services to San Francisco IDUs; however, pharmacies now augment syringe access. In addition, unsafe injection behavior is reported more often among those who do not use these syringe sources. These results are consistent with prior studies in suggesting that increasing the availability of syringes through SEPs and pharmacies, and developing bridges between them, may further reduce syringe-related risk.

Knowledge about Hepatitis-C among methadone maintenance treatment patients in Israel

Ignorance about Hepatitis-C (HCV) among drug users, treatment staff, and policy makers thwarts treatment uptake and facilitates virus transmission. We assessed knowledge about HCV among methadone patients in Israel, where effective HCV-treatment is provided at low-cost within the national health insurance framework, yet few infected methadone patients are treated. In 2006, 512 patients in two methadone clinics in Israel were interviewed, of whom 53% were HCV-positive. The clinics were purposively selected from the 11 methadone clinics in the country. Respondents exhibited poor knowledge about HCV, particularly about diagnosis and treatment. Lesser-educated respondents were three times more likely to score low on HCV-knowledge compared to those with 12+ years of schooling (AOR = 2.97, 95% CI = 1.5-5.7. HCV-negative patients were also three-times more likely than HCV-positive patients to score low on the HCV-knowledge scale (Adjusted Odds Ratio = 3.0, 95% Confidence Interval = 1.9-4.7). Enhancing HCV-knowledge may help patients avoid becoming infected and infecting others, allay exaggerated fears about hepatitis, and facilitate HCV-treatment initiation among those infected.

Prevalence rates and risk factors for hepatitis C among drug users not in treatment in Malaysia

INTRODUCTION AND AIMS

The prevalence of hepatitis C virus (HCV) among heroin dependants in treatment was estimated at 89.9%; however, virtually no information exists on the prevalence or risk behaviour among the larger population of drug users not in treatment. This study assessed the prevalence of HCV and associated risk factors among this group with a view to designing more effective intervention programs.

DESIGN AND METHODS

A cross-sectional survey of 552 not-in-treatment drug users recruited from five key urban centres across peninsular Malaysia with on-site serological testing for HCV and HIV seropositivity was conducted.

RESULTS

HCV prevalence was 65.4% for the overall sample, but higher among injecting drug users (67.1%) relative to non-injecting drug users (30.8%). Bivariate analysis suggested seven risk factors though only sharing injecting paraphernalia and lifetime homosexual/bisexual behaviour remained significant in multivariate analysis.

DISCUSSION AND CONCLUSIONS

With the majority (65.9%) sharing injecting equipment and about the same proportion (65.4%) being HCV positive, the risk of further transmission to new drug users is high. It is imperative that the nascent needle and syringe exchange and condom distribution program and its ancillary services--launched in 2005 to fight HIV--be fine tuned, as a first step, to control HCV. With its greater infectivity and non-symptomatic character, HCV is more insidious. Given the shared risk factors of HCV and HIV, routine screening of drug users for HCV--currently non-existent--should be instituted. This, with other intervention measures, will help detect and control HCV at an earlier stage while also checking the spread of HIV.

New challenges for mathematical and statistical modeling of HIV and hepatitis C virus in injecting drug users

Injecting drug users are not only driving blood-borne transmission of HIV and hepatitis C virus but also likely drive sexual transmission of HIV in large parts of the world. Mathematical and statistical modeling can provide important insights in these epidemiological processes and on the potential impact of interventions but have been little used to date. This review aims to discuss the potential areas of application of modeling in the field of viral infections in injecting drug users. After reviewing key examples of published modeling work on HIV and hepatitis C virus in injecting drug users, we discuss recent developments in the epidemiology, diagnosis, treatment and prevention of these infections. In particular, new methods for the diagnosis of early HIV infection, new antivirals for a more effective treatment of HIV, hepatitis B and hepatitis C virus infections, new concepts in design and surveillance of interventions for drug users and increasing possibilities of molecular typing of pathogens are changing the questions and decisions for public health policy makers who deal with drug-related infectious diseases. Research including mathematical modeling is needed to understand the impact of new diagnostic tools, new treatment options and combined intervention strategies on the epidemiology of viral infections in injecting drug users. Methodological advances in mathematical modeling are required to adequately approach some of the ensuing research questions. Modeling has much to offer for solving urgent policy questions, but current levels of funding in modeling research are insufficient and need to be scaled up to make better use of these possibilities.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.