Structural factors that promote stigmatization of drug users with hepatitis C in hospital emergency departments

Stigma power in practice: Exploring the contribution of Bourdieu's theory to stigma, discrimination and health research

Stigma and discrimination are increasingly understood as shaping health, and in turn conceptualised as social processes shaped by power and structural inequities. A challenge to analysis and implementing interventions is developing theory that can integrate analysis of structure, agency and power. One theoretical framework already promoted by prominent scholars as supporting this need is Bourdieu's social practice theory. This paper explores the application to date of Bourdieu's theory on stigma, discrimination and health. The paper describes how existing health literature has used concepts of symbolic violence, fields, capitals and habitus to develop insight into stigma power. The discussion explores how this theoretical framework is though underutilised and there has been little consideration of new programmatic approaches based on this theory. Directions for future research include the need for integrated approaches to analysis, especially using habitus to explore stigma power, and addressing processes of change. Directions for conceptualising interventions address how a mismatch of field and habitus could foster change and then the role for prophets in fostering symbolic revolutions. All these potential directions must in turn be integrated within the vast scholarship on stigma. In conclusion, further application and development of Bourdieu's social practice theory could help address the theoretical challenges facing the field of stigma, discrimination and health research.

Addiction stigma and opioid use in chronic non-cancer pain management in Nigeria

This study uses 26 in-depth interviews conducted with people who use drugs (PWUD) who had sought care for chronic non-cancer pain in public health facilities in Nigeria, to explore how drug consumption stigma constitutes patient legitimacy based on neoliberal ideals. It found drug consumption stigma to be salient and pervasive in PWUD health-care encounters, operating through interpersonal interactions and institutionalised policies and practices to shape access to care. Crucially, stigma emerged through disciplinary opioid prescribing and dispensing practices that defined, categorised and marginalised PWUD based on how their drug consumption disrupted normative values of rationality and responsibility. Accounts additionally revealed disengagement from biomedical care and reliance on alternative pain management approaches (e.g. herbal remedies and illegal drugs), which show how structural positions shape the exercise of choice and agency in socially marginalised populations. In conclusion, the study considers the need to improve the health-care experiences of PWUD as a strategy for enhancing health-care engagement and improving health outcomes. It called for interventions to address the structural factors and interactional dynamics that influence stigma in health-care settings as well as for a review of current guidelines and practices to improve access to opioids for chronic non-cancer pain management.

Hepatitis C Cascade of Care in the Direct-Acting Antivirals Era: A Meta-Analysis

INTRODUCTION

The hepatitis C virus (HCV) epidemic remains a public health problem worldwide. A systematic review and meta-analysis were conducted to provide evidence of outcomes attained across the HCV care cascade in the era of direct-acting antivirals.

METHODS

Studies from North America, Europe, and Australia (January 2014 through March 2021) reporting on HCV care cascade outcomes (screening to cure) were included. When calculating the proportions of individuals completing each step, the numerator for Steps 1-8 was the number of individuals completing each step; the denominator was the number of individuals completing the previous step for Steps 1-3 and Step 3 for Steps 4-8. In 2022, random effects meta-analyses were conducted to estimate pooled proportions with 95% CIs.

RESULTS

Sixty-five studies comprising 7,402,185 individuals were identified. Among individuals with positive HCV ribonucleic acid test results, 62% (95% CI=55%, 70%) attended their first care appointment, 41% (95% CI=37%, 45%) initiated treatment, 38% (95% CI=29%, 48%) completed treatment, and 29% (95% CI=25%, 33%) achieved cure. HCV screening rates were 43% (95% CI=22%, 66%) in prisons or jails and 20% (95% CI=11%, 31%) in emergency departments. Linkage to care rates were 62% (95% CI=46%, 75%) for homeless individuals and 26% (95% CI=22%, 31%) for individuals diagnosed in emergency departments. Cure rates were 51% (95% CI=30%, 73%) in individuals with substance use disorder and 17% (95% CI=17%, 17%) in homeless individuals. Cure rates were lowest in the U.S.

DISCUSSION

Despite the availability of effective all-oral direct-acting antiviral therapies, persistent gaps remain across the HCV care cascade, especially among traditionally marginalized populations. Public health interventions targeting identified priority areas (e.g., emergency departments) may improve screening and healthcare retention of vulnerable populations with HCV infection (e.g., substance use disorder populations).

Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study

BACKGROUND

Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.

METHODS

We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants' accounts.

RESULTS

Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: "being 'worthy' of the cure", "spatially enacted stigma", "countering social and structural vulnerability: the importance of peers", "identity disruption and contagion: attaining a 'social cure'" and "challenging stigma with population-based screening". Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and 'normalizing' hepatitis C among the general population.

CONCLUSIONS

Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.

A National Portrait of Public Attitudes toward Opioid Use in the US: A Latent Class Analysis

BACKGROUND

Opioid overdose rates have steadily been increasing in the United States (US) creating what is considered an overdose death crisis. The US has a mixture of public health and punitive policies aimed to address opioid use and the overdose crisis, yet little is known about public opinion relating to opioid use and policy support. Understanding the intersection of public opinion about opioid use disorder (OUD) and policy can be useful for developing interventions to address policy responses to overdose deaths.

METHODS

A national sample of cross-sectional data from the AmeriSpeak survey conducted from 27 February 2020 through 2 March 2020 was analyzed. Measures included attitudes toward OUD and policy beliefs. Latent class analysis, a person-centered approach, was used to identify groups of individuals endorsing similar stigma and policy beliefs. We then examined the relationship between the identified groups (i.e., classes) and key behavioral and demographic factors.

RESULTS

We identified three distinct groups: (1) "High Stigma/High Punitive Policy", (2) "High Stigma/Mixed Public Health and Punitive Policy", and (3) "Low Stigma/High Public Health Policy". People with higher levels of education had reduced odds of being in the "High Stigma/High Punitive Policy" group.

CONCLUSION

Public health policies are most effective in addressing OUD. We suggest targeting interventions toward the "High Stigma/Mixed Public Health and Punitive Policy" group since this group already displays some support for public health policies. Broader interventions, such as eliminating stigmatizing messaging in the media and redacting punitive policies, could reduce OUD stigma among all groups.

Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice

BACKGROUND

People who use drugs (PWUD) frequent emergency departments at a higher rate than the general population, and experience a greater frequency of soft tissue infections, pneumonia, and chronic conditions such as, HIV/AIDs and hepatitis C. This population has distinct health care considerations (e.g. withdrawal management) and are also more likely to leave or be discharged from hospital against medical advice.

METHODS

This study examines the experiences of PWUD who have left or been discharged from hospital against medical advice to understand the structural vulnerabilities that shape experiences with emergency departments. Semi-structured qualitative interviews were conducted with 30 PWUD who have left or been discharged from hospital against medical advice within the past two years as part of a larger study on hospital care and drug use in Vancouver, Canada.

RESULTS

Findings characterize the experiences and perceptions of PWUD in emergency department settings, and include: (1) stigmatization of PWUD and compounding experiences of discrimination; (2) perceptions of overall neglect; (3) inadequate pain and withdrawal management; and (4) leaving ED against medical advice and a lack of willingness to engage in future care.

CONCLUSIONS

Structural vulnerabilities in ED can negatively impact the care received among PWUD. Findings demonstrate the need to consider how structural factors impact care for PWUD and to leverage existing infrastructure to incorporate harm reduction and a structural competency focused care. Findings also point to the need to consider how withdrawal and pain are managed in emergency department settings.

A universal precautions approach to reducing stigma in health care: getting beyond HIV-specific stigma

Background

Delivery of effective health care is hampered by stigma, the social processes that attach negative judgement and response to some attributes, conditions, practices and identities. Experiencing or anticipating stigma can lead to a range of practical impacts, including avoidance of health care. While we are concerned about the stigma that is attached to HIV, this commentary makes the argument that the health system is burdened by stigma of many origins.

Main body

Reducing stigma is a key issue in improving quality of health care. Our focus on HIV is about providing better care in a non-judgemental, respectful and dignified manner which enhances the health and well-being of individuals as well as delivering benefit to society at large through better population health outcomes. However, the same could be said for the numerous possible attributes, conditions, practices and identities that attract stigma. It is unrealistic to expect health systems to respond to siloed appeals for change and action. A unifying logic is needed to propel concerns about stigma to the front of the queue for action by health systems.

Conclusion

This commentary suggests the need for a universal precautions approach to stigma in health care, that focuses on recognising that all people may experience stigma and discrimination targeted at one or more aspects of their identities, attributes, practices and health conditions. Drawing on health system precepts of equity, access and quality of care, we argue that a universal precautions approach to reducing stigma of all origins can effect everyday aspects of policy, procedure and practice to improve outcomes for individuals and for population health.

Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research

BACKGROUND

Stigma is an important element in the experience of living with chronic viral hepatitis B (HBV) and C (HCV), impacting healthcare access and uptake as well as health outcomes. Conceptualisations of stigma in research are, however, often assumed and implicit. This study aimed to synthesise and critically engage with the qualitative literature to provide an overarching conceptualisation of stigma as it pertains to viral hepatitis.

METHODS

We critically reviewed qualitative literature that mobilised concepts or theories of stigma in relation to viral hepatitis. We searched seven electronic databases for peer-reviewed literature from 2000 to 2019. Given a dearth of conceptual literature on HBV stigma, we conducted a thematic analysis of concepts deployed to theorise stigma in relation to HCV.

RESULTS

We found 13 studies that conceptualised stigma in relation to HCV, yet none for HBV. We synthesise the analytical findings of these studies and explore how HCV is theorised in relation to four themes: 'identity', 'embodiment', 'institutionalisation', and 'structuration'. Taken together, these themes illustrate the way in which HCV stigma manifests as the confluence of normative assumptions of socially unacceptable practices relating to HCV, such as injecting drug use and sexual behaviours; attitudes towards socially excluded populations; and fears of contracting a contagious and chronic illness. As such, operating within political, social, and economic systems, HCV stigma can act to silence the needs of those with HCV through misrecognising the multifaceted identities of individuals with HCV and structural determinants of health. Stigma, which is built and perpetuated by institutional arrangements, as well as in social processes and policies, shapes deservedness to, as well as engagements with, health and social care.

CONCLUSION

While commonly employed as a framing concept, much research lacks explicit theoretical or critical engagement on how stigma is conceptualised. There is a tendency for qualitative, empirical research to focus on risk factors shaping individual behaviour change, rather than on risk contexts and socio-structural change. Approaches to address stigma in relation to HCV must consider how stigma operates throughout social processes and is embedded in systems of power and normalised in institutional operating systems.

Media framing of emergency departments: a call to action for nurses and other health care providers

BACKGROUND

As part of a larger study focused on interventions to enhance the capacity of nurses and other health care workers to provide equity-oriented care in emergency departments (EDs), we conducted an analysis of news media related to three EDs. The purpose of the analysis was to examine how media writers frame issues pertaining to nursing, as well as the health and social inequities that drive emergency department contexts, while considering what implications these portrayals hold for nursing practice.

METHODS

We conducted a search of media articles specific to three EDs in Canada, published between January 1, 2018 and May 1, 2019. Media items (N = 368) were coded by story and theme attributes. A thematic analysis was completed to understand how writers in public media present issues pertaining to nursing practice within the ED context.

RESULTS

Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses. Second, media writers portray pressures experienced by nurses working in the ED in a way that evades structural determinants of quality of care. Underlying both themes is an absence of perspectives and authorship from practicing nurses themselves.

CONCLUSIONS

We recommend that frontline nurses be prioritized as experts in public media communications. Nurses must be supported to gain critical media skills to contribute to media, to destigmatize the health care needs of people experiencing inequity who attend their practice, and to shed light on the structural causes of pressures experienced by nurses working within emergency department settings.

Basic care as exceptional care: addiction stigma and consumer accounts of quality healthcare in Australia

The discrimination faced by people understood to have alcohol or other drug addictions has been the subject of extensive research, with many studies documenting experiences of stigma within healthcare services. Building on this literature, we examine the role of stigma in shaping the healthcare expectations of people seen as affected by alcohol and other drug addictions. Our analysis draws on recent theorisations of stigma as a process of social production to analyse in-depth, qualitative interviews with 20 people who had recently attended an inpatient withdrawal management service. Participants describe as exceptional forms of care that are often taken for granted by other members of the community. We argue that routinised experiences of discrimination work to constitute basic care as exceptional. This finding is significant for two reasons: (1) people who consume alcohol and other drugs often have complex healthcare needs and already encounter obstacles to accessing the care they need, and (2) by positioning people who consume drugs outside the purview of healthcare, this dynamic obstructs their fundamental right to care. We conclude by reflecting on the implications of these findings for those who are often positioned as not entitled to high quality healthcare.

Health Professional Stigma as a Barrier to Contingency Management Implementation in Opioid Treatment Programs

Contingency management (CM) has robust evidence of effectiveness as an adjunct to medication for opioid use disorders. However, CM implementation in opioid treatment programs has been limited by a myriad of well-documented barriers. One relatively unexplored barrier that may hinder CM implementation is health professional stigma toward patients with opioid use disorders. Qualitative interviews were conducted with 43 health professionals (21 leaders, 22 front-line counselors) from 11 different opioid treatment programs across Rhode Island to explore their familiarity with CM and to elucidate barriers and facilitators to CM implementation. Interviews were transcribed and coded by 3 independent raters using a reflexive team approach. Transcripts were analyzed for both a priori and emergent themes. Health professional stigma was identified as an emergent major theme with 4 distinct subthemes: (a) distrust of patients (44%, N = 19); (b) infantilizing views about patients (19%, N = 8); (c) belief that patients do not deserve prizes (19%, N = 8); and (d) recognition of patient self-stigma and community-based stigma (23%, N = 10). In addition, we identified multiple instances of health professional use of potentially stigmatizing language toward patients with opioid use disorders via terms such as drug abuser, addict, and clean or dirty urine screens (70%, N = 30). Stigma themes were identified in 86% of the transcripts, highlighting potential targets for multilevel implementation strategies. Findings of this study suggest that multiple types of health professional stigma should be considered and proactively addressed in efforts by psychologists to implement CM and other evidence-based interventions in opioid treatment programs.

Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

INTRODUCTION

Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings.

METHODS

We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted.

RESULTS

Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed.

CONCLUSION

At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Exclusion and hospitality: the subtle dynamics of stigma in healthcare access for people emerging from alcohol and other drug treatment

This article explores the role of drug use-related stigma in constraining access to healthcare services. Drawing on interviews with 20 people conducted shortly after leaving an Australian alcohol and other drug withdrawal management unit, the article explores their willingness and ability to access primary care, hospital and further services. It finds repeated descriptions of feeling ignored and shamed during efforts to access care, with some descriptions relating to subtle signs of disapproval or condemnation, and others to being ignored or dismissed. Some accounts additionally emphasise unwelcoming atmospheres, and exclusion by omission of signals of welcome and encouragement. The article goes on to consider, for the first time in this field, contemporary notions of welcome and hospitality as outlined within the cosmopolitanism tradition, asking whether they offer insights into how healthcare may become more accessible for people who regularly experience stigmatisation. In concluding, the article considers the need to think further about forms of exclusion that occur when social and individual histories of stigma are not institutionally recognised, and measures to counter these histories are not actively adopted.

Applying a diffusion of innovations framework to the scale-up of direct-acting antiviral therapies for hepatitis C virus infection: Identified challenges for widespread implementation

BACKGROUND AND AIMS

Interferon-free, direct-acting antivirals (DAAs) for hepatitis C virus (HCV) offer much promise to achieve World Health Organization targets by 2030. However, impediments at the practitioner and health-system level will continue to obstruct the scale-up of DAAs worldwide unless identified and acted upon. Applying a diffusion of innovations framework, the aim of this study was to identify structural factors impacting practitioner experiences of managing HCV treatment.

METHODS

In-depth, semi-structured, telephone interviews took place between September 2018 and April 2019 to investigate barriers and facilitators for engaging in HCV management and DAA therapy amongst general practitioners (GPs) who prescribe opioid agonist therapy and drug and alcohol specialists in Australia. Interviews were transcribed verbatim, de-identified, and coded, and data were analysed with iterative categorisation and thematic analysis using Everett Rogers's diffusion of innovation framework.

RESULTS

amongst 30 participants (12 GPs, 18 drug and alcohol specialists), several structural factors were reported to impede practitioner efforts to deliver optimal HCV care. Two primary themes were explored: contextual factors for the diffusion of DAA therapies, including attempts by participants to shift clinic culture and respond to siloed health structures, and adopter factors. Some participants chose to 'rock the boat' by circumventing clinic protocol and HCV guidelines to treat more clients, effectively shifting adopter categories to become greater advocates in HCV care. Also, while a role for GPs as the 'new adopters' in HCV management was discussed, many participants expressed uncertainty as to how much GPs should become involved in the diffusion of DAA therapies more widely.

CONCLUSIONS

Reducing the global burden of HCV infection will not be possible without the widespread delivery of HCV treatment amongst practitioners. Practitioners and health workers require leadership and resources from health authorities so that the individual and population-level benefits of DAA therapy are realised.

Stigmatisation of those with mental health conditions in the acute general hospital setting. A qualitative framework synthesis

RATIONALE

Patients with long-term mental health conditions often have complex physical, mental, and social needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the acute healthcare setting, to target areas for future intervention.

OBJECTIVE

A synthesis of qualitative literature was undertaken in order to understand how patients with long-term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system.

METHOD

A theory-driven framework approach was implemented. Existing stigma theory was used to outline a framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system.

RESULTS

A systematic literature search of qualitative studies identified a sample of 51 studies that would inform the framework. Using data in these studies, a final theoretical 'best fit' framework was developed. In this framework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance, rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours - valuing, adjustment, responding, legitimising, and positive action - which contrast with the stigmatisation patterns.

CONCLUSIONS

The study offers a framework for identifying stigmatisation and positive treatment of those with mental health conditions in an acute health setting. This framework is of potential value in targeting areas for improved quality of care and may have utility beyond this setting and stigmatised group.

Studies on stigma regarding hearing impairment and hearing aid use among adults of working age: a scoping review

PURPOSE

Research on stigma has been criticized for centering on the perceptions of individuals and their effect on social interactions rather than studying stigma as a dynamic and relational phenomenon as originally defined by Goffman. This review investigates whether and how stigma has been evaluated as a social process in the context of hearing impairment and hearing aid use.

MATERIALS AND METHODS

Systematic literature searches were conducted within four major databases for peer-reviewed journal articles on hearing impairment and hearing aid rehabilitation. In these, 18 studies with stigma, shame or mental wellbeing as the primary research interest were identified. The reports were examined for their methodology, focus and results.

RESULTS

The reviewed studies used both quantitative and qualitative methodologies, questionnaires and interviews being the most common methods. All studies concentrated on the participants' experiences or views concerning stigma. Studies examining the social process of stigmatization were lacking. Most studies pointed out the negative effect of stigma on the use of hearing aids.

CONCLUSIONS

In order to understand the process of stigmatization, more studies using observational methods are needed. Moreover, additional research should also focus on how stigma as a social and relational phenomenon can be alleviated. IMPLICATIONS FOR REHABILITATION Low adherence in hearing aid use is connected to fear of stigma related to hearing impairment and hearing aids. Hearing health services should include counseling to deal with individual's experiences and fear of stigma. Stigmatization is a social process that concerns individuals with hearing impairment in contact with their social environment. Hearing health professionals should consider including close relatives and/or partners of hearing impaired individuals in discussions of starting hearing aid rehabilitation. In consulting patients with hearing impairment professionals should give advice about how to deal with questions of hearing aid, hearing impairment and fear of stigma at work.

Determinants of hepatitis C antiviral effectiveness awareness among people who inject drugs in the direct-acting antiviral era

BACKGROUND & AIMS

Although people who inject drugs (PWID) are at greatest risk of hepatitis C (HCV), treatment uptake in this population has historically been low. Highly effective direct acting antiviral (DAA) treatments for HCV have recently become available. Our aim was to assess the awareness among PWID of these new therapies and their effectiveness.

METHODS

A national survey of PWID attending injecting equipment provision sites in Scotland during 2015-2016 included questions to gauge the awareness in this population of antiviral treatment and the high cure rates associated with new therapies (defined here as >80%).

RESULTS

Among 2623 PWID, 92% had ever been tested for HCV. After excluding those ever treated for HCV (n = 226), 79% were aware of HCV treatment. Awareness was more likely among those who had ever been tested and self-reported either a positive (adjusted odds ratio: 16.04, 95%CI 10.57-24.33) or negative (3.11, 2.30-4.22) test result, compared to those who were never tested. The minority of all respondents (17%) were aware of high cure rates. This awareness was more likely among those who had ever been in HCV specialist care (9.76, 5.13-18.60) and those who had not been in specialist care but had been tested and self-reported either a positive (3.91, 2.20-7.53) or negative (2.55, 1.35-4.81) test result, compared to those who had never been tested.

CONCLUSION

We found poor awareness of the high cure rates associated with DAAs among PWID in Scotland, despite relatively high rates of HCV testing in this population. Increased effort is needed to ensure population groups with high risk of HCV infection are fully informed of the highly effective antiviral medications now available to treat this chronic disease.

Hepatitis C Testing, Status and Treatment among Marginalized People Who Use Drugs in an Inner City Setting: An Observational Cohort Study

BACKGROUND

Chronic hepatitis C virus (HCV) infection is common among people who inject drugs (PWID) and is associated with morbidity and premature death. Although HCV can be cured, treatment may be inaccessible. We studied HCV testing, status and treatment among marginalized people who use drugs in Ottawa, Canada, a setting with universal insurance coverage for physician services.

METHODS

We analyzed data from the Participatory Research in Ottawa: Understanding Drugs study, a cross-sectional, peer-administered survey of people who use drugs from 2012 to 2013. We linked responses to population-based health administrative databases and used multivariable Poisson regression to identify factors independently associated with self-reported HCV testing, self-reported positive HCV status, and database-determined engagement in HCV treatment.

RESULTS

Among 663 participants, 562 (84.8%) reported testing for HCV and 258 (45.9%) reported HCV-positive status. In multivariable analysis, HCV-positive status was associated with female gender (RR 1.27; 95%CI 1.04 to 1.55), advancing age (RR 1.03/year; 95%CI 1.02 to 1.04), receiving disability payments (RR 1.42; 95%CI 1.06 to 1.91), injecting drugs (RR 5.11; 95%CI 2.64 to 9.91), ever injecting with a used needle (RR 1.30; 95%CI 1.12 to 1.52), and ever having taken methadone (RR 1.26; 95%CI 1.05 to 1.52). Of HCV positive participants, 196 (76%) were engaged in primary care but only 23 (8.9%) had received HCV therapy. Conclusions/Importance: Although HCV testing and positive status rates are high among PWID in our study, few have received HCV treatment. Innovative initiatives to increase access to HCV treatment for PWID are urgently needed.

Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.

The Role of Physicians’ Attitudes and the Provision of Hepatitis C Virus Treatment to People Who Inject Drugs

Inadequate hepatitis C virus (HCV) assessment and treatment among people who inject drugs (PWID) is a result of patient, provider and health system level barriers. Low HCV treatment rates continue even though guidelines have been revised to consider HCV treatment among PWID on a case-by-case basis. If accessibility to HCV treatment were increased, especially to PWID this would greatly decrease the pool of communicable disease. In order to successfully control and prevent HCV infection PWID must be actively engaged in the treatment process. Physicians’ attitudes towards HCV treatment can be represented in studies as views that are directly perceived by the physician or indirectly as perceived by the patient who is under the care of the physician. The current review focuses on examining both the indirect and direct views of physician’s attitudes in treating HCV-infected PWID and examines how this influences and impacts provision of HCV treatment. A review of the literature suggests that physician’s have varied attitudes towards their patients who use recreational drugs and who are HCV positive. Moreover it is the negative associations between HCV and drug use that can impact HCV treatment accessibility and affect the number of people who can actively begin treatment.

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study

BACKGROUND

Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem.

METHODS

Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The 'framework method' was used to analyse the data with key themes identified.

RESULTS

Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave 'prima-facie' reasons for non-attendance including 'not a priority' and 'forgot'. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. 'priority' to score drugs and the 'cost of travel' and (ii) clinic service e.g. 'difficult journey' to the clinic and timing of the 'appointment'. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself.

CONCLUSION

The study revealed that beneath apparently simple explanations for non-attendance, such as clients' chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients' perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective.

Negotiating substance use stigma: the role of cultural health capital in provider-patient interactions

Diverse aspects of life and lifestyles, including stigmatised attributes and behaviors are revealed as providers and patients discuss health. In this article, we examine how the stigma associated with substance use issues shapes clinical interactions. We use the theoretical framework of cultural health capital (CHC) to explain how substance use stigma is created, reinforced and sometimes negotiated as providers and patients engage in health interactions. We present two main findings using examples. First, two theoretical concepts--habitus and field--set the social position and expectations of providers and patients in ways that facilitate the stigmatisation of substance use. Second, we found both providers and patients actively exchanged CHC as a key strategy to reduce the negative effects of stigma. In some clinical encounters, patients possessed and activated CHC, providers acknowledged patient's CHC and CHC was successfully exchanged. These interactions were productive and mutually satisfying, even when patients were actively using substances. However, when CHC was not activated, acknowledged and exchanged, stigma was unchallenged and dominated the interaction. The CHC theoretical framework allows us to examine how the stigma process is operationalized and potentially even counteracted in clinical interactions.

Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada

Aims

Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision.

Methods

EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada.

Findings

The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges.

Conclusions

Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.