Hepatitis B virus and hepatitis C virus services offered by substance abuse treatment programs in the United States

Does the Strategy of Risk Group Testing for Hepatitis C Hit the Target?

In the European Union, it is estimated that there are 5.5 million individuals with chronic infection of hepatitis C. Intravenous drug abuse is undoubtedly the key source of the hepatitis C epidemic in Europe and the most efficient mode of transmission of HCV infections (primarily due to short incubation time, but also because the virus is introduced directly into the blood stream with the infected needle). Potentially high-risk and vulnerable populations in Europe (and the world) include immigrants, prisoners, sex workers, men having sex with men, individuals infected with HIV, psychoactive substance users etc. Since there is a lack of direct evidence of clinical benefits of HCV testing, decisions related to testing are made based on indirect evidence. Clinical practice has shown that HCV antibody tests are mostly adequate for identification of HCV infection, but the problem is that this testing strategy does not hit the target. As a result of this health care system strategy, a large number of infected patients remain undetected or they are diagnosed late. There is only a vague link between screening and treatment outcomes since there is a lack of evidence on transmission risks, multiple causes, risk behavior, ways of reaching screening decisions, treatment efficiency, etc. According to results of limited number of studies it can be concluded that there is a need to develop targeted programmes for detection of HCV and other infections, but there also a need to decrease potential harms.

Medical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection

Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy.

Examination of the Hepatitis C Virus care continuum among individuals with an opioid use disorder in substance use treatment

BACKGROUND

Hepatitis C Virus (HCV) risk is elevated for individuals with an opioid use disorder (OUD). Routine HCV testing is recommended for high-risk individuals, including those with an injection drug use history. HCV antibody testing addresses the first step in the HCV treatment care cascade, with uptake and completion of HCV treatment among individuals with chronic HCV as the optimal care cascade endpoint. The aim of this study was to characterize self-reported HCV treatment cascade outcomes among individuals with an OUD in outpatient medication assisted treatment (MAT).

METHODS

Individuals receiving methadone or buprenorphine treatment (N=202, 67.8% female, M age=35.0, SD=8.4) completed a brief, anonymous paper-and-pencil survey examining self-reported history of HCV testing, diagnosis, and treatment. Descriptive statistics characterized HCV treatment cascade outcomes.

RESULTS

A majority (79.3%) endorsed a lifetime HCV testing history; 34.9% were tested for HCV during the past year. Of those with a lifetime HCV testing history, 42.7% indicated they have been told they have HCV (n=67/157), with 21% (n=14/67) of those individuals reporting that they have been told they have chronic HCV, and 71.4% (n=10/14) of those with chronic HCV reporting receipt of HCV treatment.

DISCUSSION

Results underscore gaps in the HCV care continuum among individuals with OUD in MAT. Interventions to increase uptake of HCV testing, communication of HCV diagnostic and treatment information by medical providers, linkage to HCV medical care, and uptake and adherence to HCV treatment are urgently needed, particularly among individuals with an OUD in MAT.

Willingness to Receive Treatment for Hepatitis C among Injecting Drug Users on Methadone Program: Implications for Education and Treatment

BACKGROUND

Hepatitis C virus (HCV) is common among people who inject drugs (PWID) on methadoneprogram in Iran (Persia). However, a few PWID on methadone program report willingness to receive HCVtreatment. This study aimed to assess the factors which were associated with willingness to receive HCVtreatment in a group of PWID on methadone program in Iran.

METHODS

We surveyed 187 PWID at seven drops in centers in Tehran, Iran. Details of demographiccharacteristics, drug use, injection, HCV, and drug treatment history were collected using a 25-itemquestionnaire. Participants were serologically tested for the current status of HCV.

FINDINGS

The study found that 28.3% of the participants were HCV seropositive. In total, 49.1% of theparticipants reported unwillingness to receive HCV treatment. Awareness of current HCV status [odds ratio(OR) = 3.43; 95% confidence interval (CI): 1.33-7.26; P < 0.050]; adequate knowledge of HCV treatmentcenters in the community (OR = 3.9; 95% CI: 1.24-5.38; P < 0.050); participation in an educational programon HCV (OR = 2.9; 95% CI: 2.33-8.56; P < 0.001) and recent participation in the meetings of self-helpgroups (OR = 4.6; 95% CI: 3.43-9.33; P < 0.001) were significantly associated with current willingness toreceive HCV treatment.

CONCLUSION

The study results indicate that awareness of HCV status and the provision of adequate HCVeducation via different information centers can be associated with an increased willingness for HCVtreatment among PWID on methadone program. Conducting more research is suggested to assess theefficacy of educational programs and self-help groups in facilitating HCV treatment among PWID onmethadone program.

Hepatitis C virus-related knowledge and willingness to receive treatment among patients on methadone maintenance

OBJECTIVES

Although persons who inject drugs have high prevalence of hepatitis C virus (HCV) infection, few receive treatment mostly because of lack of knowledge about the infection and its treatment. We assessed the level of HCV-related knowledge and willingness to participate in HCV treatment among methadone-maintained patients.

METHODS

A 30-item survey covering HCV-related knowledge and willingness to engage in HCV-related education and treatment was developed and completed by 320 methadone-maintained patients.

RESULTS

Respondents' mean age was 53 ± 8.7 years, 59.5% were male, 55.1% were African American, and 38.3% were Hispanic. The mean duration of methadone maintenance was 7 ± 6.7 years. In the preceding 6 months, 6.9% of patients reported injection drug use, whereas 37.3% used noninjection drugs. Hepatitis C virus seropositivity was self-reported by 46.3% of patients. The majority of patients (78%) expressed willingness to participate in HCV-related education and to receive HCV treatment. Most patients (54.7%) correctly answered 5 or more of 7 questions assessing HCV knowledge. Hepatitis C virus-seropositive individuals and prior attendees at HCV-related educational activities demonstrated a higher level of HCV-related knowledge (P < 0.001 and P = 0.002, respectively). Younger patients (P = 0.014), those willing to attend an HCV-related educational activity (P < 0.001), and those with higher-HCV-related knowledge (P = 0.029) were more accepting of HCV treatment. Fear of medication-related side effects was the most common reason for treatment avoidance.

CONCLUSIONS

The majority of patients reported willingness to receive HCV-related education and treatment. Treatment willingness was significantly associated with previous attendance at an HCV educational activity and a higher level of HCV-related knowledge.

Accelerated Hepatitis A and B Immunization in a Substance Abuse Treatment Program

An accelerated dosing program for hepatitis A and B vaccination among veterans receiving treatment for addictive disorders was successfully implemented, although many veterans with hepatitis C did not complete the immunization series.

Cost-effectiveness of rapid hepatitis C virus (HCV) testing and simultaneous rapid HCV and HIV testing in substance abuse treatment programs

AIMS

To evaluate the cost-effectiveness of rapid hepatitis C virus (HCV) and simultaneous HCV/HIV antibody testing in substance abuse treatment programs.

DESIGN

We used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer, off-site HCV testing referral, on-site rapid HCV testing offer and on-site rapid HCV and HIV testing offer. Base case inputs included 11% undetected chronic HCV, 0.4% undetected HIV, 35% HCV co-infection among HIV-infected, 53% linked to HCV care after testing antibody-positive and 67% linked to HIV care. Disease outcomes were estimated from established computer simulation models of HCV [Hepatitis C Cost-Effectiveness (HEP-CE)] and HIV [Cost-Effectiveness of Preventing AIDS Complications (CEPAC)].

SETTING AND PARTICIPANTS

Data on test acceptance and costs were from a national randomized trial of HIV testing strategies conducted at 12 substance abuse treatment programs in the United States.

MEASUREMENTS

Lifetime costs (2011 US$) and quality-adjusted life years (QALYs) discounted at 3% annually; incremental cost-effectiveness ratios (ICERs).

FINDINGS

On-site rapid HCV testing had an ICER of $18,300/QALY compared with no testing, and was more efficient than (dominated) off-site HCV testing referral. On-site rapid HCV and HIV testing had an ICER of $64,500/QALY compared with on-site rapid HCV testing alone. In one- and two-way sensitivity analyses, the ICER of on-site rapid HCV and HIV testing remained <$100,000/QALY, except when undetected HIV prevalence was <0.1% or when we assumed frequent HIV testing elsewhere. The ICER remained <$100,000/QALY in 91% of probabilistic sensitivity analyses.

CONCLUSIONS

On-site rapid hepatitis C virus and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/quality-adjusted life year threshold.

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.

The impact of lifetime drug use on hepatitis C treatment outcomes in insured members of an integrated health care plan

BACKGROUND

The relation of drug use to HCV treatment outcome in an insured household population has not been previously reported.

METHODS

Lifetime frequencies of marijuana use and non-medical use of stimulants, sedatives, and opioids; hallucinogens; and inhalants were retrospectively assessed in 259 privately insured members of an integrated health care plan treated for chronic hepatitis C virus infection (HCV+) with pegylated interferon alpha and ribavirin and examined with respect to rates of sustained virological response (SVR).

RESULTS

The majority of patients reported chronic use of multiple illegal drugs; 61.6% reported injection drug use (IDU); 79.5% abstained from drug use during the six months prior to HCV treatment. Total frequency of individual drugs, multiple drugs, and length of abstention from drugs prior to HCV treatment were not related to impaired SVR rates. Sustained viral responses were obtained in 80.2% of patients with HCV genotype 2/3 and 45.1% of patients with genotype 1/4/6. Marijuana use during HCV treatment, reported by 8.5% of patients, was associated with higher treatment adherence (95.5% compared with 78.9%, p=0.045), but lower SVR rates (40.9% compared with 62.5%, p=0.041). In addition, drug use during HCV treatment was associated with significantly higher relapse rates, 18.8% compared with 7.7% (p=0.053).

CONCLUSION

A history of chronic illegal drug use should not be considered a deterrent to HCV treatment in members of an integrated health care plan who are motivated to seek treatment and closely monitored, but drug use during HCV treatment, including marijuana use, should be discouraged.

Hepatitis C virus control among persons who inject drugs requires overcoming barriers to care

Despite a high prevalence of hepatitis C virus (HCV) infection, the vast majority of persons who inject drugs (PWID) have not engaged in HCV care due to a large number of obstacles. Education about the infection among both PWID and providers remains an important challenge as does discrimination faced by PWID in conventional health care settings. Many providers also remain hesitant to prescribe antiviral therapy due to concerns about adherence and relapse to drug use resulting in reinfection. Presently, however, as a result of improvements in treatment efficacy combined with professional society and government endorsement of HCV treatment for PWID, a pressing need exists to develop strategies to engage these individuals into HCV care. In this article, we propose several strategies that can be pursued in an attempt to engage PWID into HCV management. We advocate that multidisciplinary approaches that utilize health care practitioners from a wide range of specialties, as well as co-localization of medical services, are strategies likely to result in increased numbers of PWID entering into HCV management. Pursuit of HCV therapy after stabilization through drug treatment is an additional strategy likely to increase PWID engagement into HCV care. The full impact of direct acting antivirals for HCV will only be realized if innovative approaches are pursued to engage all HCV infected individuals into treatment.

Missed opportunities for hepatitis C testing in opioid treatment programs

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.

A qualitative analysis of provider barriers and solutions to HIV testing for substance users in a small, largely rural southern state

PURPOSE

Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas.

METHODS

We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data.

FINDINGS

The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility.

CONCLUSIONS

This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.