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Beard N, McGrath M, Scott D, Nehme Z, Lubman DI, Ogeil RP. Using ambulance surveillance data to characterise blood-borne viral infection histories among patients presenting with acute alcohol and other drug-related harms. Emerg Med Australas 2024; 36:536-542. [PMID: 38414361 DOI: 10.1111/1742-6723.14394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/24/2024] [Accepted: 02/14/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Preventable transmission of blood-borne viruses (BBV), including human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV), continue in at-risk populations, including people who use alcohol and drugs (AODs). To our knowledge, no studies have explored the use of ambulance data for surveillance of AOD harms in patients with BBV infections. METHODS We used electronic patient care records from the National Ambulance Surveillance System for people who were attended by an ambulance in Victoria, Australia between July 2015 and July 2016 for AOD-related harms, and with identified history of a BBV infection. Descriptive and geospatial analyses explored the epidemiological and psychosocial characteristics of patients for these attendances. RESULTS The present study included 1832 patients with a history of a BBV infection who required an ambulance for AOD-related harms. Amphetamines were reported in 24.7% of attendances where the patient identified HIV history, and heroin was reported more often for patients with viral hepatitis history (HCV: 19.2%; HBV: 12.7%). Higher proportions of attendances with a viral hepatitis history were observed in patients from the most socially disadvantaged areas. Geospatial analyses revealed higher concentrations of AOD attendances with a BBV history occurring in metropolitan Melbourne. CONCLUSIONS Our study describes the utility of ambulance data to identify a sub-population of patients with a BBV history and complex medical and social characteristics. Repeat attendances of BBV history patients to paramedics could present an opportunity for ongoing surveillance using ambulance data and possible paramedic intervention, with potential linkage to appropriate BBV services.
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Affiliation(s)
- Naomi Beard
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Michael McGrath
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School and Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Debbie Scott
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School and Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School and Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rowan P Ogeil
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School and Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
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Conway A, Marshall AD, Crawford S, Hayllar J, Grebely J, Treloar C. Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study. Implement Sci 2023; 18:22. [PMID: 37296448 DOI: 10.1186/s13012-023-01281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic. METHODS Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access. RESULTS We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses. CONCLUSIONS The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW, Sydney, Australia.
- Centre for Social Research in Health, UNSW, Sydney, Australia.
| | - Alison D Marshall
- The Kirby Institute, UNSW, Sydney, Australia
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | | | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, Australia
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia
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Riley F, Harris M, Poulter HL, Moore HJ, Ahmed D, Towl G, Walker T. 'This is hardcore': a qualitative study exploring service users' experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England. Harm Reduct J 2023; 20:66. [PMID: 37173697 PMCID: PMC10182620 DOI: 10.1186/s12954-023-00785-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/16/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context. METHODS We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT. RESULTS Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement. CONCLUSIONS The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.
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Affiliation(s)
- Fleur Riley
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK.
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, England, UK
| | - Hannah Louise Poulter
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, England, UK
| | - Helen J Moore
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, England, UK
| | - Daniel Ahmed
- Foundations Medical Practice, Acklam Road, Middlesbrough, TS5 4EQ, England, UK
| | - Graham Towl
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK
| | - Tammi Walker
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK
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Razaghi E, Farhoudian A, Pilevari A, Noroozi A, Hooshyari Z, Radfar R, Malekinejad M. Identification of the socio-cultural barriers of drug addiction treatment in Iran. Heliyon 2023; 9:e15566. [PMID: 37131427 PMCID: PMC10149210 DOI: 10.1016/j.heliyon.2023.e15566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/04/2023] Open
Abstract
Introduction Socio-cultural norms can either be encouraging or a barrier to addiction treatment. More, rigorous research is needed on nonindigenous models in addiction treatment, to better understand the role of socio-cultural differences. Methods The present qualitative study is part of the project, "The Inclusive Assessment of the Barriers of Drug Addiction Treatment Services in Iran," which was conducted in Tehran from 2018 to 2021. The participants consisted of eight people who used drugs, seven individual family members of the people who used drugs participants, seven service providers, and four policymakers. A purposeful sampling method was used for the selection of the participants, and the process continued until reaching the theoretical saturation of data. Analysis used the Graneheim and Lundman methods, classifying primary codes, the sub-themes, and themes were classified according to the similarities and differences between primary codes. Finding The most important socio-cultural barriers to addiction treatment in Iran are: unrealistic expectations of the family and society from the people who use drugs, addiction stigma, mistrust between various components of the treatment system, perceptions that professional substance use disorder treatment is inefficient and low uptake of that treatment, the disturbed relational boundaries between the people who use drugs and their relatives, the interweaving of treatment and ethical and religious principles, low acceptance of maintenance treatments, treatment focusing on short-term outcomes, and presence of facilitating backgrounds of using drugs. Conclusions The Iranian socio-cultural characteristics play an important role in the addiction treatment of the people who use drugs, so it is necessary for treatment interventions to be sensitive to these characteristics.
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Affiliation(s)
- Emran Razaghi
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Farhoudian
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Azam Pilevari
- Department of Sociology, Kharazmi University, Karaj, Iran
- Corresponding author.
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Science, Tehran, Iran
| | - Zahra Hooshyari
- Department of Geriatric Medicine, Ziaeian Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
- Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Radfar
- Department of Neuroscience and Addiction, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Malekinejad
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, USA
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Poulter HL, Walker T, Ahmed D, Moore HJ, Riley F, Towl G, Harris M. More than just 'free heroin': Caring whilst navigating constraint in the delivery of diamorphine assisted treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 116:104025. [PMID: 37062231 DOI: 10.1016/j.drugpo.2023.104025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND In 2020, drug related deaths in the United Kingdom (UK) reached the highest rate in over 25 years, with hospitalisations and deaths particularly impacting people who use illicit opioids such as heroin. Treatment systems are increasingly required to be innovative to engage the most vulnerable at risk from premature morbidity and mortality. Heroin Assisted Treatment (HAT) is an alternative treatment modality for people for whom more traditional forms of opioid substitution therapy, such as methadone, have been ineffective. Middlesbrough, a town in the North-East England, was home to the first service in the UK to implement HAT outside of a clinical trial setting which closed for operation in November 2022. METHODS Qualitative in-depth interviews with patients and health care providers (n =17) involved in the delivery of HAT were undertaken during 2021. This paper focuses on the health care provider interviews, the majority of which took place remotely. Interviews were audio recorded and thematically analysed. RESULTS Health care providers navigated multiple layers of constraint during HAT implementation and delivery. We explore this in relation to three themes: 1) Negotiating risk and safety within treatment 2) More than a prescription: care beyond diamorphine 3) Internal and external delivery barriers and impact on treatment acceptability, identity and longevity. Negotiating and managing risks of polysubstance use was a complex task. Benefits regarding access to holistic care, improved therapeutic and social relationships were recognised by practitioners. The rigorous delivery schedule was the biggest barrier to engagement. Outside the treatment room, socio-structural factors posed additional challenges. CONCLUSION Despite some operational complexities, health care providers viewed HAT as an effective method of engaging a high risk population with drug treatment services, with holistic benefits for clients over and above the treatment of opioid dependency. Findings will inform advocacy and innovation for future HAT interventions in England.
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Affiliation(s)
- Hannah Louise Poulter
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, United Kingdom.
| | - Tammi Walker
- Durham University, Department of Psychology, England, UK
| | - Danny Ahmed
- Clinical Lead, Foundations Medical Practice, Acklam Road, Middlesbrough, TS5 4EQ, United Kingdom
| | - Helen J Moore
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, United Kingdom
| | - Fleur Riley
- Durham University, Department of Psychology, England, UK
| | - Graham Towl
- Durham University, Department of Psychology, England, UK
| | - Magdalena Harris
- London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society, England, UK
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Conway A, Valerio H, Alavi M, Silk D, Treloar C, Hajarizadeh B, Marshall AD, Martinello M, Milat A, Dunlop A, Murray C, Prain B, Henderson C, Amin J, Read P, Marks P, Degenhardt L, Hayllar J, Reid D, Gorton C, Lam T, Christmass M, Wade A, Montebello M, Dore GJ, Grebely J. A Testing Campaign Intervention Consisting of Peer-Facilitated Engagement, Point-of-Care HCV RNA Testing, and Linkage to Nursing Support to Enhance Hepatitis C Treatment Uptake among People Who Inject Drugs: The ETHOS Engage Study. Viruses 2022; 14:1555. [PMID: 35891535 PMCID: PMC9316739 DOI: 10.3390/v14071555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
This study evaluated HCV treatment initiation among people who inject drugs (PWID) following an intervention of campaign days involving peer connection, point-of-care HCV RNA testing, and linkage to nursing support. ETHOS Engage is an observational cohort study of PWID attending 25 drug treatment clinics and needle and syringe programs in Australia (May 2018-September 2019). Point-of-care results were provided to the nurse, facilitating confirmatory testing and treatment. The study aimed to evaluate treatment uptake and factors associated with treatment at 24 months post-enrolment. There were 317 people with current HCV infection and eligible for treatment (median age 43, 65% male, 15% homeless, 69% receiving opioid agonist treatment, 70% injected in last month). Overall, 15% (47/317), 27% (85/317), 38% (120/317), and 49% (155/317) of people with current HCV infection had initiated treatment at 3-, 6-, 12-, and 24-months following testing, respectively. Homelessness (adjusted hazard ratio (aHR): 0.40; 95% confidence interval: 0.23, 0.71) and incarceration in the past 12 months (vs. never, aHR:0.46; 0.28, 0.76) were associated with decreased treatment initiation in the 24 months post-enrolment. This testing campaign intervention facilitated HCV treatment uptake among PWID. Further interventions are needed to achieve HCV elimination among people experiencing homelessness or incarceration.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Heather Valerio
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Maryam Alavi
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - David Silk
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Behzad Hajarizadeh
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Alison D. Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Marianne Martinello
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Andrew Milat
- Centre for Epidemiology and Evidence, NSW Health, Sydney, NSW 2065, Australia;
| | - Adrian Dunlop
- Hepatitis NSW, Surry Hills, NSW 2010, Australia;
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW 2300, Australia
| | - Carolyn Murray
- Population Health Strategy & Performance, NSW Health, Sydney, NSW 2065, Australia; (C.M.); (B.P.)
| | - Bianca Prain
- Population Health Strategy & Performance, NSW Health, Sydney, NSW 2065, Australia; (C.M.); (B.P.)
| | | | - Janaki Amin
- Department of Health Systems and Populations, Macquarie University, Sydney, NSW 2109, Australia;
| | - Phillip Read
- Kirketon Road Centre, Sydney, NSW 2010, Australia;
| | - Pip Marks
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW 2052, Australia;
| | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, QLD 4029, Australia;
| | - David Reid
- Drug and Alcohol Service, Illawarra Shoalhaven Local Health District, Wollongong, NSW 2500, Australia;
| | - Carla Gorton
- Cairns Sexual Health Service, Cairns, QLD 4870, Australia;
| | - Thao Lam
- Drug Health, Western Sydney Local Health District, Sydney, NSW 2145, Australia;
| | - Michael Christmass
- Next Step Community Alcohol and Drug Service, Perth, WA 6004, Australia;
- National Drug Research Institute, Curtin University, Perth, WA 6102, Australia
| | - Alexandra Wade
- Mid North Coast Liver Clinic, Mid North Coast Local Health District, Coffs Harbour, NSW 2450, Australia;
- Drug and Alcohol Services, Mid North Coast Local Health District, Coffs Harbour, NSW 2450, Australia
| | - Mark Montebello
- North Sydney Local Health District, Sydney, NSW 2077, Australia;
| | - Gregory J. Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; (H.V.); (M.A.); (D.S.); (B.H.); (A.D.M.); (M.M.); (P.M.); (G.J.D.); (J.G.)
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Examining Relational Dimensions of Service Encounters for Disadvantaged People Who Use Drugs. J Addict Nurs 2022; 33:159-167. [DOI: 10.1097/jan.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tang W, Tao Y, Fajardo E, Reipold EI, Chou R, Tucker JD, Easterbrook P. Diagnostic Accuracy of Point-of-Care HCV Viral Load Assays for HCV Diagnosis: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:1255. [PMID: 35626411 PMCID: PMC9141110 DOI: 10.3390/diagnostics12051255] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 01/13/2023] Open
Abstract
Despite the widespread availability of curative treatment with direct-acting antivirals, a significant proportion of people with HCV remain undiagnosed and untreated. New point-of-care (PoC) HCV RNA assays that can be used in clinical settings may help expand access to testing and treatment. This study aimed to evaluate the diagnostic performance of PoC HCV viral load assays compared to laboratory-based testing. Methods: We searched three databases for studies published before May 2021 that evaluated PoC HCV RNA assays against a laboratory NAT reference standard (Prospero CRD42021269022). Random effects bivariate models were used to summarize the estimates. Stratified analyses were performed based on geographic region, population (PWID, etc.), and specimen type (serum/plasma or fingerstick; fresh or frozen). We used the GRADE approach to assess the certainty of the evidence. Results: A total of 25 studies were eligible. We evaluated five different commercially available viral load assays. The pooled sensitivity and specificity were 99% (95% CI: 98−99%) and 99% (95% CI: 99−100%), respectively. High sensitivity and specificity were observed across different assays, study settings (including LMICs and HICs), and populations. There was a small but statistically significant reduction in sensitivity for fingersticks compared to serum or plasma samples (98% vs. 100%, p < 0.05), but the specificity was similar between frozen and fresh samples. The evidence was rated as moderate-high certainty. Conclusions: PoC HCV viral load assays demonstrate excellent diagnostic performance in various settings and populations. The WHO now recommends using PoC HCV viral load assays as an additional strategy to promote access to confirmatory viral load testing and treatment.
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Affiliation(s)
- Weiming Tang
- University of North Carolina Project-China, Guangzhou 510095, China; (Y.T.); (J.D.T.)
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chaple Hill, Chapel Hill, NC 27599, USA
| | - Yusha Tao
- University of North Carolina Project-China, Guangzhou 510095, China; (Y.T.); (J.D.T.)
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chaple Hill, Chapel Hill, NC 27599, USA
| | - Emmanuel Fajardo
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, 1211 Geneva, Switzerland; (E.F.); (P.E.)
| | | | - Roger Chou
- Departments of Medicine, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou 510095, China; (Y.T.); (J.D.T.)
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chaple Hill, Chapel Hill, NC 27599, USA
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, 1211 Geneva, Switzerland; (E.F.); (P.E.)
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Holeksa J. Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city. Harm Reduct J 2022; 19:23. [PMID: 35246162 PMCID: PMC8894830 DOI: 10.1186/s12954-022-00602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/17/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. METHODS Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. RESULTS Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. CONCLUSION Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.
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Affiliation(s)
- Julie Holeksa
- Department of Social Work, Faculty of Health and Society, Malmö University, Citadellsvägen 7, 211 18, Malmö, Sweden.
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Doran J, Hope V, Wright T, Scott J, Ciccarone D, Harris M. Prevalence and factors associated with chronic venous insufficiency, leg ulceration and deep-vein thrombosis among people who inject drugs in London, UK. Drug Alcohol Rev 2021; 41:677-685. [PMID: 34605086 DOI: 10.1111/dar.13389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/16/2021] [Accepted: 09/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION People who inject drugs (PWID) are vulnerable to a range of harms, including vascular conditions such as chronic venous insufficiency (CVI), leg ulcers and deep vein thrombosis (DVT). The extent of vascular conditions has rarely been studied, despite contributing to considerable illness and disability among PWID. We assess the prevalence and associations of vascular conditions in PWID in London, UK. METHODS Survey data from the community-recruited Care and Prevent Study of PWID in London were analysed. Participants were asked about CVI and leg ulcers using pictorial questions, and if they had ever been diagnosed with DVT. Associations between vascular conditions and demographic/drug-use information were explored using univariate and multivariable logistic regression. RESULTS Among participants (n = 455), the prevalence of CVI, leg ulcers and DVT was 13% (n = 57), 10% (n = 46) and 23% (n = 105), respectively. CVI and DVT were positively associated with injecting into the groin, while injecting into the leg was positively associated with leg ulcers and DVT. CVI was also associated with not cleaning injection sites and diagnosed hepatitis C virus, and DVT with hepatitis C virus. DISCUSSION AND CONCLUSION The prevalence of vascular problems among PWID in London is very high in comparison to the general population. These conditions are primarily associated with injection into the femoral vein. Use of these injection sites indicates peripheral venous access problems. There is a need to reinvigorate safe injection information provision in harm reduction services, with attention to reducing risk practices associated with venous damage and transitions to femoral injection.
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Affiliation(s)
- Jason Doran
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,National Infection Service, Public Health England, London, UK
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Talen Wright
- Division of Psychiatry, University College London, London, UK
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, USA
| | - Magdalena Harris
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Lafferty L, Cochrane A, Sheehan Y, Treloar C, Grebely J, Lloyd AR. "That was quick, simple, and easy": Patient perceptions of acceptability of point-of-care hepatitis C RNA testing at a reception prison. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 99:103456. [PMID: 34560624 DOI: 10.1016/j.drugpo.2021.103456] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Current diagnostic pathways require multiple healthcare provider visits and lead to a drop-off in the hepatitis C virus (HCV) testing and treatment care cascade. In prison settings, frequent transitioning between prisons and the community further reduces uptake of testing and treatment. The PIVOT study evaluated a 'one-stop-shop' intervention integrating point-of-care HCV RNA testing, Fibroscan®-based liver disease assessment, and treatment prescription at a reception prison in Australia. This qualitative sub-study was undertaken to assess patient acceptability of point-of-care HCV RNA testing in the reception prison setting. METHODS Twenty-four men in prison enrolled in the PIVOT study participated in semi-structured interviews; all of whom had undergone point-of-care HCV RNA testing in the PIVOT study. Patients were purposefully selected to ensure comparable representation of people with and without a history of injecting drug use and people with and without prior HCV testing experience (standard venepuncture). Sekhon's Theoretical Framework of Acceptability, consisting of seven components (affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness, and self-efficacy), informed this qualitative analysis. RESULTS Acceptability of fingerstick point-of-care HCV RNA testing was evident across four components: affective attitude, burden, self-efficacy, and perceived effectiveness. Patients described point-of-care testing as "quick and easy" (affective attitude), while swift results were viewed as alleviating anxiety associated with long wait times for standard pathology (burden). Patients averse to venepuncture (e.g., fear of needles or poor vein health) found the fingerstick method accessible, thereby enabling participation in HCV screening (self-efficacy). Participants attributed confidence in test results predominantly due to trust in the healthcare system or trust in the personnel administering the test (perceived effectiveness). CONCLUSION People entering custody perceive fingerstick HCV RNA point-of-care testing to be an acceptable method and preferred this method to standard HCV testing via venepuncture. In light of these findings, prison health authorities should consider the role of opt-out point-of-care HCV RNA testing upon prison entry.
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Affiliation(s)
- Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Level 1, Goodsell Building, Sydney, NSW, 2052, Australia; The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia.
| | - Amanda Cochrane
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia; Justice and Forensic Mental Health Network, NSW Health, PO Box 150, Matraville, NSW, 2036, Australia
| | - Yumi Sheehan
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Level 1, Goodsell Building, Sydney, NSW, 2052, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia
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12
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Harris M, Guy D, Picchio CA, White TM, Rhodes T, Lazarus JV. Conceptualising hepatitis C stigma: A thematic synthesis of qualitative research. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103320. [PMID: 34261587 DOI: 10.1016/j.drugpo.2021.103320] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/20/2021] [Accepted: 05/23/2021] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH
| | - Danielle Guy
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Trenton M White
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain
| | - Tim Rhodes
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036 Barcelona, Spain; Faculty of Medicine, University of Barcelona, Barcelona, Spain.
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13
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Grebely J, Tran L, Degenhardt L, Dowell-Day A, Santo T, Larney S, Hickman M, Vickerman P, French C, Butler K, Gibbs D, Valerio H, Read P, Dore GJ, Hajarizadeh B. Association Between Opioid Agonist Therapy and Testing, Treatment Uptake, and Treatment Outcomes for Hepatitis C Infection Among People Who Inject Drugs: A Systematic Review and Meta-analysis. Clin Infect Dis 2021; 73:e107-e118. [PMID: 32447375 PMCID: PMC8246796 DOI: 10.1093/cid/ciaa612] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/20/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) experience barriers to accessing testing and treatment for hepatitis C virus (HCV) infection. Opioid agonist therapy (OAT) may provide an opportunity to improve access to HCV care. This systematic review assessed the association of OAT and HCV testing, treatment, and treatment outcomes among PWID. METHODS Bibliographic databases and conference presentations were searched for studies that assessed the association between OAT and HCV testing, treatment, and treatment outcomes (direct-acting antiviral [DAA] therapy only) among PWID (in the past year). Meta-analysis was used to pool estimates. RESULTS Of 9877 articles identified, 22 studies conducted in Australia, Europe, North America, and Thailand were eligible and included. Risk of bias was serious in 21 studies and moderate in 1 study. Current/recent OAT was associated with an increased odds of recent HCV antibody testing (4 studies; odds ratio (OR), 1.80; 95% confidence interval [CI], 1.36-2.39), HCV RNA testing among those who were HCV antibody-positive (2 studies; OR, 1.83; 95% CI, 1.27-2.62), and DAA treatment uptake among those who were HCV RNA-positive (7 studies; OR, 1.53; 95% CI, 1.07-2.20). There was insufficient evidence of an association between OAT and treatment completion (9 studies) or sustained virologic response following DAA therapy (9 studies). CONCLUSIONS OAT can increase linkage to HCV care, including uptake of HCV testing and treatment among PWID. This supports the scale-up of OAT as part of strategies to enhance HCV treatment to further HCV elimination efforts.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, Sydney, New South Wales, Australia
| | - Lucy Tran
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
| | | | - Thomas Santo
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, England
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, England
| | - Clare French
- Population Health Sciences, University of Bristol, Bristol, England
| | - Kerryn Butler
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
- Discipline of Addiction Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Daisy Gibbs
- National Drug and Alcohol Research Centre, Sydney, New South Wales, Australia
| | | | - Phillip Read
- Kirketon Road Centre, Sydney, New South Wales, Australia
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Stvilia K, Vephkvadze N, Gamkrelidze A, Khonelidze I, Getia V, Tsereteli M, Gvinjilia L, Kuchuloria T. Hepatitis C treatment uptake among patients who have received methadone substitution treatment in the Republic of Georgia. Public Health 2021; 195:42-50. [PMID: 34051674 DOI: 10.1016/j.puhe.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/16/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES There is a dearth of research on hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWIDs) and receive methadone substitution treatment (MST) in Eastern Europe and Central Asia countries. This study contributed to addressing that gap. We examined and identified factors that may affect HCV treatment uptake among PWID who received MST in the Republic of Georgia. STUDY DESIGN The design of the study is retrospective cohort study. METHODS We conducted HCV care cascade analysis by matching the data from the web-based national hepatitis C program registry (ELIM C) and the MST treatment database between January 1, 2015, and December 31, 2018. Using the World Health Organization's (WHO) Consensus HCV cascade of care (CoC) global instrument, we assessed the progress made toward the country's 2020 and WHO's 2030 hepatitis C elimination targets for the subpopulation of MST patients. RESULTS Overall, 10,498 individuals have been dispensed methadone during the study period. A total of 6828 MST beneficiaries had HCV screening, of whom 5843 (85.6%) tested positive; 5476 (93.7%) were tested for HCV viremia, and 5275 (96.3%) were confirmed with chronic HCV infection. More than 75% (n = 4000) of HCV-infected MST patients initiated HCV treatment, and 3772 (94.3%) completed the treatment. Of those eligible for sustained virologic response assessment, 71.0% (2641/3715) were evaluated, and the reported cure rate was 96.1% (2537). The study found the odds of patients starting HCV treatment differed by the type of facility they were screened at and whether they were registered as PWID at the screening sites. The patients screened at centers with integrated HCV treatment services had higher treatment uptake rates than those screened at other centers. CONCLUSIONS As the cumulative HCV treatment uptake and cure rates among MST patients with HCV infection are high (75.8% and 96.1%, respectively), the MST patients might become the first microelimination target population in which hepatitis C elimination will be achieved in Georgia. The study found the type of screening facility and whether MST patients registered themselves as PWID or not had significant effects on MST patients starting HCV treatment. At the same time, the study did not find gender and age to be significant predictors of MST patients starting HCV treatment. MST patients used different types of health facilities to get screened for HIV. Many of them did not register themselves as PWID when screened for HIV. The existence of only a few harm reduction sites with integrated HCV treatment services, a high level of stigma, and the criminalization of drug use might have incentivized MST patients to self-navigate across the HCV care continuum with the rest of the population. The implementation of focused, harm reduction, integrated HCV treatment with good peer and professional adherence support at treatment sites could help reach the hepatitis C elimination goals among MST patients.
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Affiliation(s)
- Ketevan Stvilia
- National Center for Disease Control and Public Health, Georgia.
| | | | | | - Irma Khonelidze
- National Center for Disease Control and Public Health, Georgia
| | - Vladimer Getia
- National Center for Disease Control and Public Health, Georgia
| | - Maia Tsereteli
- National Center for Disease Control and Public Health, Georgia
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15
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Ndimbii J, Guise A, Igonya EK, Owiti F, Strathdee S, Rhodes T. Qualitative Analysis of Community Support to Methadone Access in Kenya. Subst Use Misuse 2021; 56:1312-1319. [PMID: 34027819 PMCID: PMC10708729 DOI: 10.1080/10826084.2021.1922450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Methadone, as part of Medically Assisted Therapy (MAT) for treatment of opioid dependence and supporting HIV prevention and treatment, has been recently introduced in Kenya. Few low income settings have implemented methadone, so there is little evidence to guide ongoing scale-up across the region. We specifically consider the role of community level access barriers and support. OBJECTIVES To inform ongoing MAT implementation we implemented a qualitative study to understand access barriers and enablers at a community level. METHODS We conducted 30 semi-structured interviews with people who use drugs accessing MAT, supplemented by interviews with 2 stakeholders, linked to participant observation in a community drop in center within one urban area in Kenya. We used thematic analysis. RESULTS We developed five themes to express experiences of factors enabling and disabling MAT access and how community support can address these: 1) time, travel and economic hardship; 2) managing methadone and contingencies of life, 3) peer support among MAT clients as treatment ambassadors, 4) family relations, and 5)outreach project contributions. Crosscutting themes address managing socioeconomic constraints and gender inequities. CONCLUSIONS People who use drugs experience and manage socio-economic constraints and gender inequities in accessing MAT with the support of local communities. We discuss how these access barriers could be addressed through strengthening the participation of networks of people who use drugs in drug treatment and supporting community projects working with people who use drugs. We also explore potential for how socio-economic constraints could be managed within an integrated health and social care response.
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Affiliation(s)
| | - Andy Guise
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Emmy Kageha Igonya
- School of Medicine, University of Nairobi, Nairobi, Kenya
- Kenya & African Population and Health Research Center, Nairobi, Kenya
| | - Frederick Owiti
- School of Medicine, University of Nairobi, Nairobi, Kenya
- Kenya & African Population and Health Research Center, Nairobi, Kenya
| | - Steffanie Strathdee
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Tim Rhodes
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK
- University of New South Wales, Syndey, Australia
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Goodyear T, Brown H, Browne AJ, Hoong P, Ti L, Knight R. "Stigma is where the harm comes from": Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103238. [PMID: 33902968 DOI: 10.1016/j.drugpo.2021.103238] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/16/2021] [Accepted: 03/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment. METHODS We thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post). RESULTS Our analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts. CONCLUSIONS DAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.
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Affiliation(s)
- Trevor Goodyear
- School of Nursing, University of British Columbia, Vancouver, Canada; British Columbia Centre on Substance Use, Vancouver, Canada
| | - Helen Brown
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Peter Hoong
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada.
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17
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Goodyear T, Brown H, Browne AJ, Hoong P, Ti L, Knight R. "I want to get better, but…": identifying the perceptions and experiences of people who inject drugs with respect to evolving hepatitis C virus treatments. Int J Equity Health 2021; 20:81. [PMID: 33740984 PMCID: PMC7977167 DOI: 10.1186/s12939-021-01420-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The advent of highly tolerable and efficacious direct-acting antiviral (DAA) medications has transformed the hepatitis C virus (HCV) treatment landscape. Yet, people who inject drugs (PWID) - a population with inequitably high rates of HCV and who face significant socio-structural barriers to healthcare access - continue to have disproportionately low rates of DAA uptake. The objective of this study is to explore how PWID with lived experience of HCV perceive and experience DAA treatment, in a setting with universal coverage of these medications since 2018. METHODS Informed by a critical interpretive framework, we thematically analyze data from in-depth, semi-structured interviews conducted between January and June 2018 in Vancouver, Canada, with a purposive sample (n = 56) of PWID at various stages (e.g., pre, peri, post) of DAA treatment. RESULTS The analysis yielded three key themes: (i) life with HCV, (ii) experiences with and perceptions of evolving HCV treatments, and (iii) substance use and the uptake of DAA treatments. First, participants described how health and healthcare conditions, such as the deprioritizing of HCV (e.g., due to: being asymptomatic, healthcare provider inaction, gatekeeping) and catalysts to care (e.g., symptom onset, treatment for co-morbidities) shaped DAA treatment motivation and access. Second, participants described how individual and community-level accounts of evolving HCV treatments, including skepticism following negative experiences with Interferon-based treatment and uncertainty regarding treatment eligibility, negatively influenced willingness and opportunities to access DAAs. Concurrently, participants described how peer and community endorsement of DAAs was positively associated with treatment uptake. Third, participants favoured HCV care that was grounded in harm reduction, which included the integration of DAAs with other substance use-related services (e.g., opioid agonist therapy, HIV care), and which was often contrasted against abstinence-focused care wherein substance use is framed as a contraindication to HCV treatment access. CONCLUSIONS These findings underscore several equity-oriented healthcare service delivery and clinician adaptations that are required to scale up DAAs among PWID living with HCV, including the provision of harm reduction-focused, non-stigmatizing, integrated, and peer-led care that responds to power differentials.
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Affiliation(s)
- Trevor Goodyear
- School of Nursing, University of British Columbia, Vancouver, Canada
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
| | - Helen Brown
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Peter Hoong
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, 400-1045 Howe St, V6Z 2A9, Vancouver, BC, Canada.
- Department of Medicine, University of British Columbia, Vancouver, Canada.
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18
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Abadie R, McLean K, Habecker P, Dombrowski K. Treatment trajectories and barriers in opioid agonist therapy for people who inject drugs in rural Puerto Rico. J Subst Abuse Treat 2021; 127:108347. [PMID: 34134865 DOI: 10.1016/j.jsat.2021.108347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention. METHODS We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment. RESULTS Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico. CONCLUSION Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.
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Affiliation(s)
- Roberto Abadie
- Department of Anthropology, University of Nebraska-Lincoln, 839 Old Father Hall, Lincoln, NE 68588, United States of America.
| | - Katherine McLean
- Department of Administration of Justice, Penn State Greater Allegheny, 400 University Drive, McKeesport, PA 15216, United States of America
| | - Patrick Habecker
- Department of Sociology, University of Nebraska-Lincoln, 430 Old Father Hall, Lincoln, NE 68588, United States of America
| | - Kirk Dombrowski
- Department of Anthropology, University of Vermont, 72 University Place, VT 05405, United States of America
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Rance J, Rhodes T, Lancaster K. Pharmaceutical citizenship in an era of universal access to hepatitis C treatment: Situated potentials and limits. Health (London) 2021; 26:736-752. [PMID: 33506718 DOI: 10.1177/1363459320988887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Until recently, the only medical treatment available for the hepatitis C virus (HCV) was interferon-based therapy, a notoriously long and arduous treatment with limited success. However, in December 2015, the Australian Government announced a scheme of 'universal access' to new, highly effective direct-acting antiviral therapies (DAAs). This article draws on in-depth interviews with community actors engaged in national and state-based drug user and viral hepatitis advocacy to trace how universal access to curative medicines affords revised notions of citizenship and social inclusion among people who inject drugs and others affected by HCV. To inform our analysis, we draw on and combine critical perspectives from the biological citizenship literature, particularly pharmaceutical citizenship, along with work on the concepts of 'publics and counterpublics'. We ask: what kinds of emergent HCV communities or publics are being enacted through our participant accounts in response to the new DAA-era of universal access, and what forms of citizenship and inclusion (or non-citizenship and exclusion) do they postulate? Some accounts indeed enacted treatment as an individual, sometimes collective, 'good': a citizenship potential. However, a number of accounts enacted situated limits to a straightforward actualisation of this potential, performing a model of public health governance that prioritised viral cure whilst rendering injecting drug use and its attendant social disadvantages an absent presence. Reconceptualising HCV treatment within a counterpublic health sensibility would, by engaging with the everyday health needs and aspirations of people living with HCV in conditions of social disadvantage, create space for new social inclusions and citizenships.
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Affiliation(s)
| | - Tim Rhodes
- UNSW Sydney, Australia.,London School of Hygiene and Tropical Medicine, UK
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Jack K, Linsley P, Thomson BJ, Irving WL. How do people in prison feel about opt-out hepatitis C virus testing? J Viral Hepat 2020; 27:1003-1011. [PMID: 32488916 DOI: 10.1111/jvh.13338] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/16/2020] [Accepted: 04/28/2020] [Indexed: 12/18/2022]
Abstract
The prison population is central to the campaign to eliminate hepatitis C virus as a public health threat. In the UK, this has led to the introduction of a national 'opt-out' policy, requiring people in prison to be tested for HCV unless they decline, with a target to test 75% of those admitted. However, in a representative prison estate in the East Midlands of England (20,000 prison entrants per annum) testing rates were only 13.4%. This qualitative study explains why the rates of test uptake are so far short of target. This qualitative study examines the experiences of 45 people in prison about hepatitis C virus testing in an English category C (low security) prison. The data collection method was semi-structured interviews. The data were coded and analysed according to the research questions, and interpretation of the data was aided by the use of a thematic network approach. The themes Fear, Insufficient Knowledge, Stigma, Privacy, Choice and Prison Life emerged as the principal barriers to test uptake. Test Uptake Facilitators that promoted testing were identified by participants and benefits presented of prison health care being a Health Farm. In order to increase hepatitis C virus test uptake, significant changes and flexibility in the timing, location, and staff deployed to test are required. Providing information to people in prison about hepatitis C virus transmission and treatment may reduce fears and enable the test uptake target to be met and sustained.
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Affiliation(s)
- Kathryn Jack
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | - Brian James Thomson
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - William Lucien Irving
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Wright T, Hope V, Ciccarone D, Lewer D, Scott J, Harris M. Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK. PLoS One 2020; 15:e0235350. [PMID: 32663203 PMCID: PMC7360031 DOI: 10.1371/journal.pone.0235350] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis. METHODS We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity. RESULTS We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all. CONCLUSIONS Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.
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Affiliation(s)
- Talen Wright
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
| | - Daniel Ciccarone
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Dan Lewer
- Institute of Epidemiology and Healthcare, University College London, London, United Kingdom
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Claverton Down, Bath, United Kingdom
| | - Magdalena Harris
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Harris M. Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care. Soc Sci Med 2020; 260:113183. [PMID: 32682207 PMCID: PMC7441308 DOI: 10.1016/j.socscimed.2020.113183] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 01/18/2023]
Abstract
In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017-June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a 'last resort', with admission to hospital in a critical or a "near death" condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, United Kingdom.
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23
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Shousha HI, Said M, ElAkel W, ElShafei A, Esmat G, Waked E, Elsayed MH, Doss W, Elrazky M, Mehrez M, Hassany M, Zeyada D, Anis M, Alserafy M. Assessment of facility performance during mass treatment of chronic hepatitis C in Egypt: Enablers and obstacles. J Infect Public Health 2020; 13:1322-1329. [PMID: 32473817 DOI: 10.1016/j.jiph.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/30/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The national committee for control of viral hepatitis (NCCVH) in Egypt, settled by the Ministry of health, treated over one million patients in around 60 centers with chronological changes in drug combinations. This research aims to study the health care facilities and services provided by NCCVH treatment centers in Egypt and explore hinders faced. METHODS A cross-sectional operational research study. Multistage random sampling technique was applied for Egyptian governorates. From each stratum one governorate was chosen from which one center was randomly selected. Quality of recorded data for each center in the central server (Data-oriented parameter), newly designed score to assess the overall performance of the centers was retrieved from computer based recording system. A self-administered questionnaire was completed by the centers head. RESULTS This study included 24 treatment centers from urban, rural areas, Upper and Lower Egypt. The Upper centers showed the best completeness of follow-up records and the least compliance rates. None of the centers had 100% completeness of follow-up data. Proportion of SVR is minimally less than proportion of patient with known outcome in all treatment centers. A novel indicator standardizing the comparisons of performance of different facilities was introduced: Total number of physicians/total number of SVR patients with completed records. The highest response rate: Monfiya Governorate (Lower Egypt), Aswan (Upper Egypt), Completeness of follow-up records: Kalyoubia (Lower Egypt), Sohag governorate (Upper Egypt). The average administrative score was 64%. CONCLUSION Challenges of NCCVH program: overcrowdings, resistant sociocultural background among rural patients, limited accessibility for internal migrants and incompleteness of data entry are system lacking points. Strengths include, clear patient pathway, well-established database online application, well-trained physicians and treatment availability.
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Affiliation(s)
- Hend Ibrahim Shousha
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt.
| | - Mohamed Said
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Wafaa ElAkel
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Arwa ElShafei
- Public Health and Community Medicine Department, Cairo University, Cairo, Egypt
| | - Gamal Esmat
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Emam Waked
- National Liver Institute, Menofia University, Menofia, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Manal Hamdy Elsayed
- Pediatric Department, Ain Shams University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Wahid Doss
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | - Maysa Elrazky
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt
| | - Mai Mehrez
- National Tropical Medicine& Hepatology Institute, Cairo, Egypt
| | - Mohamed Hassany
- National Tropical Medicine& Hepatology Institute, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
| | | | | | - Magdy Alserafy
- Endemic Medicine and Hepato-Gastroenterology Department, Cairo University, Cairo, Egypt; National Committee for Control of Viral Hepatitis, MOH, Cairo, Egypt
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24
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Crespo J, Cuadrado A, Perelló C, Cabezas J, Llerena S, Llorca J, Cedillo S, Llop E, Escudero MD, Hernández Conde M, Puchades L, Redondo C, Fortea JI, Gil de Miguel A, Serra MA, Lazarus JV, Calleja JL. Epidemiology of hepatitis C virus infection in a country with universal access to direct-acting antiviral agents: Data for designing a cost-effective elimination policy in Spain. J Viral Hepat 2020; 27:360-370. [PMID: 31755634 DOI: 10.1111/jvh.13238] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/30/2019] [Accepted: 11/05/2019] [Indexed: 12/29/2022]
Abstract
Accurate HCV prevalence estimates are necessary for guiding elimination policies. Our aim was to determine the HCV prevalence and assess the cost-effectiveness of a screen-and-treat strategy in the Spanish population. A population-based, cross-sectional study (PREVHEP-ETHON Cohort, Epidemiological sTudy of Hepatic infectiONs; NCT02749864) was performed from July 2015-April 2017. Participants from three Spanish regions were selected using two-stage conglomerate sampling, and stratified by age, with randomized subject selection. Anthropometric and demographic data were collected, and blood samples were taken to detect anti-HCV antibodies/quantify HCV RNA. The cost-effectiveness of the screening strategies and treatment were analysed using a Markov model. Among 12 246 participants aged 20-74 (58.4% females), the overall anti-HCV prevalence was 1.2% (95% CI 1.0-1.4), whereas the detectable HCV-RNA prevalence was 0.3% (0.2-0.4). Infection rates were highest in subjects aged 50-74 years [anti-HCV 1.6% (1.3-1.9), HCV RNA 0.4% (0.3-0.6]. Among the 147 anti-HCV + subjects, 38 (25.9%) had active infections while 109 (74.1%) had been cleared of infection; 44 (40.4%) had cleared after antiviral treatment, whereas 65 (59.6%) had cleared spontaneously. Overall, 59.8% of the anti-HCV + participants were aware of their serological status. Considering a cost of treatment of €7000/patient, implementing screening programmes is cost-effective across all age cohorts, particularly in patients aged 50-54 (negative incremental cost-effectiveness ratio which indicates a cost-saving strategy). The current HCV burden is lower than previously estimated, with approximately 25% of anti-HCV + individuals having an active infection. A strategy of screening and treatment at current treatment prices in Spain is cost-effective across all age cohorts.
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Affiliation(s)
- Javier Crespo
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, School of Medicine, University of Cantabria, Santander, Spain.,Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | - Antonio Cuadrado
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, School of Medicine, University of Cantabria, Santander, Spain.,Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | - Christie Perelló
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, School of Medicine, Universidad Autónoma Madrid, Majadahonda, Spain
| | - Joaquin Cabezas
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, School of Medicine, University of Cantabria, Santander, Spain.,Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | - Susana Llerena
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, School of Medicine, University of Cantabria, Santander, Spain.,Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | - Javier Llorca
- Department of Epidemiology and Computational Biology, School of Medicine, University of Cantabria, Santander, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), IDIVAL, s/n, Santander, Spain
| | - Sergio Cedillo
- Outcomes Research Department, Chiltern International/MSD, Tres Cantos, Spain
| | - Elba Llop
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, School of Medicine, Universidad Autónoma Madrid, Majadahonda, Spain
| | - María Desamparados Escudero
- Gastroenterology and Hepatology, Servicio Medicina Digestiva del Hospital Clinico Universitario de Valencia (HUCV) Av. de Blasco Ibáñez, Valencia, Spain
| | - Marta Hernández Conde
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, School of Medicine, Universidad Autónoma Madrid, Majadahonda, Spain
| | - Laura Puchades
- Gastroenterology and Hepatology, Servicio Medicina Digestiva del Hospital Clinico Universitario de Valencia (HUCV) Av. de Blasco Ibáñez, Valencia, Spain
| | - Carlos Redondo
- Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | - José I Fortea
- Department of Gastroenterology and Hepatology, Marqués de Valdecilla University Hospital, School of Medicine, University of Cantabria, Santander, Spain.,Marqués de Valdecilla Research Institute (IDIVAL), s/n, Calle Cardenal Herrera Oria, Santander, Spain
| | | | - Miguel A Serra
- Gastroenterology and Hepatology, Servicio Medicina Digestiva del Hospital Clinico Universitario de Valencia (HUCV) Av. de Blasco Ibáñez, Valencia, Spain
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - José Luis Calleja
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Majadahonda, School of Medicine, Universidad Autónoma Madrid, Majadahonda, Spain
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Pourmarzi D, Hall L, Smirnov A, Hepworth J, Rahman T, FitzGerald G. Framework for community-based models for treating hepatitis C virus. AUST HEALTH REV 2020; 44:459-469. [DOI: 10.1071/ah18220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/01/2019] [Indexed: 12/16/2022]
Abstract
Objective
Although community-based models for treating hepatitis C virus (HCV) are widely recognised for reaching more people who require treatment, little is known about their organisational and operational elements. This study aimed to address this gap and develop a framework for designing, implementing and evaluating community-based models for treating HCV.
Methods
This study was a systematic review in which 17 databases were searched for published and unpublished studies. The final search of databases was performed in September 2017. A qualitative inductive thematic approach was used to extract and categorise organisational and operational elements of community-based models for treating HCV.
Results
Data analysis yielded 13 organisational and operational elements that were categorised into three domains: support for patients, support for healthcare providers and service delivery facilitation. In the support for patients domain, support was categorised into four elements: peer support, psychological assessment and support, social assessment and support and adherence support. In the support for healthcare providers domain, the elements included the provision of educational opportunities for HCV care providers, specialist mentoring, decision making support and rewarding and recognition for HCV care providers. Finally, the service delivery facilitation domain included seven elements that target service-level enablers for community-based HCV treatment, including essential infrastructure, policy implementation and collocation and collaboration with other related services.
Conclusion
This framework for understanding the components of models of community-based HCV treatment may be used as a guide for designing, implementing and evaluating models of care in support of HCV elimination. HCV care providers and patients need to be supported to improve their engagement with the provision of community-based treatment. In addition, evidence-based strategies to facilitate service delivery need to be included.
What is known about the topic?
Community-based models for treating HCV are widely recognised as having the advantage of reaching more people who require treatment. These types of models aim to remove barriers related to accessibility and acceptability associated with tertiary centre-based HCV treatment.
What does this paper add?
Community-based models for treating HCV use various organisational and operational elements to improve the accessibility, effectiveness and acceptability of these services. The elements we identified target three main domains: support for patients with HCV, support for HCV care providers and service delivery facilitation. The importance of these organisational and operational elements designed to improve health and health services outcomes of community-based models for treating HCV is strongly influenced by context, and dependent on both the setting and target population.
What are the implications for practitioners?
Health policy makers and practitioners need to consider a patient’s psychosocial and economic status and provide support when needed. To successfully deliver HCV treatment in community settings, HCV care providers need to be trained and supported, and need to establish linkages, collaborations or colocations with other related services.
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26
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Litwin AH, Drolet M, Nwankwo C, Torrens M, Kastelic A, Walcher S, Somaini L, Mulvihill E, Ertl J, Grebely J. Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: The C-SCOPE Study. J Viral Hepat 2019; 26:1094-1104. [PMID: 31074167 PMCID: PMC6771477 DOI: 10.1111/jvh.13119] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/18/2019] [Accepted: 04/09/2019] [Indexed: 12/15/2022]
Abstract
The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians practicing in clinics offering opioid agonist treatment (OAT). C-SCOPE was a study consisting of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe and the United States between April and May 2017. A 5-point Likert scale (1 = not a barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to perceived barriers for HCV testing, evaluation and treatment across the domains of the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor access to on-site venepuncture (35%), point-of-care HCV testing (16%), and noninvasive liver disease assessment (25%). Only 30% of OAT physicians reported personally treating HCV infection. Major perceived health system barriers to HCV management included the lack of funding for noninvasive liver disease testing, long wait times to see an HCV specialist, lack of funding for new HCV therapies, and reimbursement restrictions based on drug/alcohol use. Major perceived clinic barriers included the lack of peer support programmes and/or HCV case managers to facilitate linkage to care, the need to refer people off-site for noninvasive liver disease staging, the lack of support for on-site phlebotomy and the lack of on-site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics.
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Affiliation(s)
- Alain H. Litwin
- Department of MedicineUniversity of South Carolina School of Medicine ‐ Greenville and Prisma HealthGreenvilleSouth Carolina,Clemson University School of Health ResearchClemsonSouth Carolina
| | | | | | - Martha Torrens
- Department of PsychiatryInstitut de Neuropsiquiatria i AddiccionsHospital del Mar BarcelonaIMIM (Institut Hospital del Mar d'Investigacions Mediques)Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Andrej Kastelic
- National Centre for the Treatment of Drug Addiction in LjubljanaLjubljanaSlovenia
| | | | - Lorenzo Somaini
- Addiction Treatment Centre ‐ Ser.D ASL BI ‐ Local Health UnitBiellaItaly
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Jack K, Thomson BJ, Irving WL. Testing for hepatitis C virus infection in UK prisons: What actually happens? J Viral Hepat 2019; 26:644-654. [PMID: 30702194 DOI: 10.1111/jvh.13071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/20/2018] [Accepted: 01/05/2019] [Indexed: 01/14/2023]
Abstract
Prisons are a key demographic in the drive to eradicate hepatitis C virus (HCV) as a major public health threat. We have assessed the impact of the recently introduced national opt-out policy on the current status of HCV testing in 14 prisons in the East Midlands (UK). We analysed testing rates pre- and post-introduction of opt-out testing, together with face-to-face interviews with prison healthcare and management staff in each prison. In the year pre-opt-out, 1972 people in prison (PIP) were tested, compared to 3440 in the year following opt-out. From July 2016 to June 2017, 2706 people were tested, representing 13.5% of all prison entrants (median 16.6%, range 7.6%-40.7%). Factors correlating with testing rates were as follows: pre-admission location of the PIP (another prison or the community, OR 2.2, 95% CI 1.9-2.3, P < 0.001); whether the PIP could access health care independently of prison officers (OR 1.7, 95% CI 1.5-1.8, P < 0.001); the absence of out-reach services for HCV treatment (OR 1.3, 95% CI 1.2-1.5, P < 0.001), whether >50% of PIP reported ease of access to a nurse (OR 2.0, 95% CI 1.8-2.2, P < 0.001), and whether prison health care was supplied by private or NHS providers (OR 1.3, 95% CI 1.2-1.5, P < 0.001). Testing rates remained far below the minimum national opt-out target of 50%. Inadequacy of healthcare facilities and constraints imposed by adherence to prison regimens were cited by healthcare and management staff at all prisons. Without radical change, the prison estate may be intrinsically incapable of supporting NHSE to deliver the HCV elimination strategy.
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Affiliation(s)
- Kathryn Jack
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Brian J Thomson
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - William L Irving
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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28
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Maticic M, Zorman JV, Gregorcic S, Schatz E, Lazarus JV. Changes to the national strategies, plans and guidelines for the treatment of hepatitis C in people who inject drugs between 2013 and 2016: a cross-sectional survey of 34 European countries. Harm Reduct J 2019; 16:32. [PMID: 31072401 PMCID: PMC6509821 DOI: 10.1186/s12954-019-0303-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/18/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is the leading cause of cirrhosis, end-stage liver disease and hepatocellular carcinoma (HCC) worldwide. In Europe, people who inject drugs (PWID) represent the majority of HCV infections, but are often excluded from treatment. The aim of this study was to report on national HCV strategies, action plans and guidelines in European countries that include HCV treatment for the general population as well as for PWID. Data on access to direct-acting antivirals (DAAs) were also collected. METHODS In 2016, 38 non-governmental organisations, universities and public health institutions that work with PWID in 34 European countries were invited to complete a 16-item online survey about current national HCV treatment policies and guidelines. Data from 2016 were compared to those from 2013 for 33 European countries, and time trends are presented. Differences in the data were analysed. Data from 2016 on general access to DAAs in PWID are presented separately. RESULTS The response rate was 100%. Fourteen countries (42%) reported having a national HCV strategy covering HCV treatment; 12 of these addressed HCV treatment for PWID. Respondents from ten countries (29%) reported having a national HCV action plan. PWID were specifically included in seven of them. Twenty-nine countries (85%) reported having national HCV treatment guidelines. PWID were specifically included in 23 (79%) of them. Compared to 2013, respondents reported that an additional seven countries (25%) had national strategies, an additional eight countries (29%) had action plans and an additional six countries (19%) had HCV treatment guidelines. However, PWID were not included in two, four and six of those countries, respectively. DAAs were reported to be available in 91% of the study countries, with restrictions reported in 71% of them. CONCLUSION Respondents reported that fewer than half of the European countries in this study had a national HCV strategy and/or action plan, with even fewer including PWID. However, when compared to 2013, the number of such countries had slightly increased. Although PWID are often addressed in clinical guidelines, strategic action is needed to increase access to HCV treatment for this group and the situation should be regularly monitored.
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Affiliation(s)
- Mojca Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Japljeva Str 2, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jerneja Videcnik Zorman
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Japljeva Str 2, 1000 Ljubljana, Slovenia
| | - Sergeja Gregorcic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Japljeva Str 2, 1000 Ljubljana, Slovenia
| | - Eberhard Schatz
- Correlation Network, Foundation De RegenboogGroep, Amsterdam, The Netherlands
| | - Jeffrey V. Lazarus
- Barcelona Institute forGlobal Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
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29
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Høj SB, Jacka B, Minoyan N, Artenie AA, Bruneau J. Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:11-23. [PMID: 31003825 DOI: 10.1016/j.drugpo.2019.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/22/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Abstract
As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.
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Affiliation(s)
- Stine Bordier Høj
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada.
| | - Brendan Jacka
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Nanor Minoyan
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Andreea Adelina Artenie
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Julie Bruneau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; Département de Médicine Familiale et Médecine d'Urgence, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada.
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Day E, Broder T, Bruneau J, Cruse S, Dickie M, Fish S, Grillon C, Luhmann N, Mason K, McLean E, Trooskin S, Treloar C, Grebely J. Priorities and recommended actions for how researchers, practitioners, policy makers, and the affected community can work together to improve access to hepatitis C care for people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 66:87-93. [DOI: 10.1016/j.drugpo.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 02/08/2023]
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Childs E, Assoumou SA, Biello KB, Biancarelli DL, Drainoni ML, Edeza A, Salhaney P, Mimiaga MJ, Bazzi AR. Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs. Harm Reduct J 2019; 16:14. [PMID: 30744628 PMCID: PMC6371610 DOI: 10.1186/s12954-019-0286-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population. METHODS We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods. RESULTS In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment. CONCLUSIONS Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.
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Affiliation(s)
- Ellen Childs
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Sabrina A Assoumou
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Katie B Biello
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Alberto Edeza
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Peter Salhaney
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
| | - Matthew J Mimiaga
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 442e, Boston, MA, 02118, USA.
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Roncero C, Ryan P, Littlewood R, Macías J, Ruiz J, Seijo P, Palma-Álvarez RF, Vega P. Practical steps to improve chronic hepatitis C treatment in people with opioid use disorder. Hepat Med 2018; 11:1-11. [PMID: 30613166 PMCID: PMC6307489 DOI: 10.2147/hmer.s187133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES People with a history of injecting drugs have high prevalence of hepatitis C virus (HCV) infection, and many have opioid use disorder (OUD). Modern HCV therapies with improved efficacy and tolerability are available, but access is often limited for this group, who may be underserved for health care and face social inequity. This work develops practical steps to improve HCV care in this population. METHODS Practical steps to improve HCV care in OUD populations were developed based on clinical experience from Spain, structured assessment of published evidence. RESULTS Options for improving care at engagement/screening stages include patient education programs, strong provider-patient relationship, peer support, and adoption of rapid effective screening tools. To facilitate work up/treatment, start options include simplified work up process, integration of HCV and OUD care, and continuous psychosocial support prior, during, and after HCV treatment. CONCLUSION It is important to plan on local basis to set up a joint integrated approach between specific drug treatment services and local points of HCV care. The elements for a specific integrated program should be chosen from options identified, including education services, peer input, organization to make HCV screening and treatment easier by co-location of services, and wider access to prescribing direct-acting antiviral (DAA) therapy.
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Affiliation(s)
- Carlos Roncero
- Psychiatric Service, University of Salamanca Health Care Complex, Institute of Biomedicine of Salamanca, University of Salamanca, Salamanca, Spain,
| | - Pablo Ryan
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | | | - Juan Macías
- Department of Infectious Diseases and Microbiology, Valme University Hospital, Seville, Spain
| | - Juan Ruiz
- Provincial Center of Drug Addiction, Malaga, Spain
| | - Pedro Seijo
- Addiction Treatment Center of Villamartín, Cádiz, Spain
| | - Raúl Felipe Palma-Álvarez
- Addiction and Dual Diagnosis Unit, Vall Hebron University Hospital, Barcelona, Spain
- Psychiatry Service, Biomedical Research Networking Center for Mental Health Network, Vall Hebron University Hospital, Barcelona, Spain
- Autonomous University of Barcelona, Barcelona, Spain
| | - Pablo Vega
- Spanish Society of Dual Diagnosis, Bilbao, Spain
- Institute of Addictions, Madrid, Spain
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Abadie R, Goldenberg S, Welch-Lazoritz M, Fisher CB. Establishing trust in HIV/HCV research among people who inject drugs (PWID): Insights from empirical research. PLoS One 2018; 13:e0208410. [PMID: 30517202 PMCID: PMC6281254 DOI: 10.1371/journal.pone.0208410] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 11/17/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The establishment of trust between researchers and participants is critical to advance HIV and HCV prevention particularly among people who inject drugs (PWID) and other marginalized populations, yet empirical research on how to establish and maintain trust in the course of community health research is lacking. This paper documents ideas about trust between research participants and researchers amongst a sub-sample of PWID who were enrolled in a large, multi-year community health study of social networks and HIV/HCV risk that was recently conducted in rural Puerto Rico. METHODS Qualitative research was nested within a multi-year Social Network and HIV/HCV Risk study involving N = 360 PWID > 18 years of age living in four small, rural Puerto Rican communities. Semi-structured interviews were conducted between March 2017 and April 2017 with a subset of 40 active PWID who had been enrolled in the parent study. Interview questions invited participants to draw upon their recent experience as research participants to better understand how PWID perceive and understand participant-researcher trust within the context of HIV/HCV-related epidemiological research. RESULTS Fear of police, stigma and concerns regarding confidentiality and anonymity were identified as structural factors that could compromise participation in HIV/HCV-related research for PWID. While monetary compensation was an important motivation, participants also valued the opportunity to learn about their HIV/HCV status. During their participation in the study, gaining knowledge of safe injection practices was perceived as a valuable benefit. Participant narratives suggested that PWID may adopt an incremental and ongoing approach in their assessment of the trustworthiness of researchers, continuously assessing the extent to which they trust the research staff throughout the course of the research. Trust was initially generated through peer Respondent Driven Sampling recruitment. Research staff who maintained a presence in the community for the entire duration of the prospective study reinforced trust between participants and the research team. CONCLUSION Although PWID face numerous structural barriers to research-related trust in HIV/HCV research, we found that using a peer-based recruitment method like RDS, and employing a research staff who are knowledgeable about the targeted population, culturally sensitive to their needs, and who maintain a long-term presence in the community may help mitigate many of these barriers. The reputation of the research is built incrementally as participants join the study. This contributes to a "street reputation" that grows as current or former participants vouch for the study. Establishing trust was identified as only the first step towards building a collaborative relationship with participants, and our findings suggest that steps to address criminalization and stigmatization also are necessary to support research trust.
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Affiliation(s)
- Roberto Abadie
- Department of Sociology, University of Nebraska-Lincoln, Lincoln, NE, United States of America
| | - Shira Goldenberg
- Faculty of Health Sciences, Simon Fraser University, Bumaby, BC, Canada
| | - Melissa Welch-Lazoritz
- Pharmaceutical and Nutrition Care, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Celia B. Fisher
- Department of Psychology, Fordham University, Bronx, NY, United States of America
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Lafferty L, Rance J, Grebely J, Lloyd AR, Dore GJ, Treloar C. Understanding facilitators and barriers of direct-acting antiviral therapy for hepatitis C virus infection in prison. J Viral Hepat 2018; 25:1526-1532. [PMID: 30141261 DOI: 10.1111/jvh.12987] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/19/2018] [Accepted: 07/27/2018] [Indexed: 01/25/2023]
Abstract
Hepatitis C virus (HCV) infection is a major public health concern. Globally, 15% of those incarcerated are HCV-antibody positive (anti-HCV). Even where HCV treatment is available within prisons, treatment uptake has remained low. This qualitative study was conducted to understand the barriers and facilitators for the delivery of HCV treatment in prisons from the perspectives of prisoners. This is important to inform health messaging for HCV treatment within correctional institutions. Thirty-two prisoners (including eight women) with a history of injecting drug use participated in this qualitative study. Participants were equally recruited across four correctional centres (n = 8 per site). Overall, 16 participants (50%) had chronic HCV at their most recent test, and two participants were awaiting test results at time of interview. Structural (eg proximity of health clinic) and patient-level (routine and motivation) factors were viewed as facilitators of HCV treatment within the prison setting. Structural (eg risk of reinfection) and social (eg lack of confidentiality and lack of social support) factors were perceived as barriers to prison-based HCV care and treatment. In conclusion, to increase HCV treatment uptake, prison-based programmes should implement (or advocate for) patient-centred treatment approaches that protect privacy, provide social support, and promote access to clean needles and substitution therapy to protect prisoners from reinfection.
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Affiliation(s)
- Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jake Rance
- Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
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Wright C, Cogger S, Hsieh K, Goutzamanis S, Hellard M, Higgs P. "I'm obviously not dying so it's not something I need to sort out today": Considering hepatitis C treatment in the era of direct acting antivirals. Infect Dis Health 2018; 24:58-66. [PMID: 30541692 DOI: 10.1016/j.idh.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND People who inject drugs are the group at greatest risk of hepatitis C virus (HCV) infection. The advent of new direct-acting antiviral (DAA) treatment provides opportunities for increased uptake of therapy. METHODS We conducted in-depth interviews with thirty HCV positive participants from the SuperMIX cohort study. Interviews were transcribed, coded, and analysed for emerging themes and similarities between participants. General descriptions and critical interpretation of themes were generated and selective quotes extracted verbatim to best illustrate the critical themes. RESULTS Participants described their experiences of living with HCV, their knowledge of HCV treatment accessibility, and information on the types of support ain themes: Understanding the need for treatment; Knowledge and framing of treatment access; and Support during treatment. CONCLUSION The new, highly effective DAAs for the treatment of HCV are heralded as the potential beginning of HCV elimination, especially in settings where scale up is high. Our data from active PWID show that the availability of DAA medications in and of themselves is likely not to be enough to ensure that PWID will come forward for HCV treatment in sufficient numbers to drive elimination.
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Affiliation(s)
- C Wright
- Burnet Institute, Melbourne, Vic 3004, Australia.
| | - S Cogger
- Burnet Institute, Melbourne, Vic 3004, Australia.
| | - K Hsieh
- Burnet Institute, Melbourne, Vic 3004, Australia.
| | - S Goutzamanis
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic 3004, Australia.
| | - M Hellard
- Burnet Institute, Melbourne, Vic 3004, Australia.
| | - P Higgs
- La Trobe University, Department of Public Health, Bundoora, Vic 3083, Australia.
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Harris M, Rhodes T. Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 60:24-32. [PMID: 30092546 DOI: 10.1016/j.drugpo.2018.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The development of simplified and effective hepatitis C (HCV) pharmaceuticals enables treatment scale up among the most marginalised. This potentiates a promise of viral elimination at the population level but also individual level clinical and non-clinical benefits. Reports of transformative non-clinical outcomes, such as changes in self-worth and substance use, are primarily associated with arduous interferon-based treatments that necessitate intensive care relationships. We consider the implications of simplified treatment provision in the era of direct acting antivirals (DAAs) for the realisation of non-clinical benefits. METHODS We draw on qualitative data from ethnographic observations and longitudinal interviews with people receiving (n = 22) and providing (n = 10) HCV treatment in London during a transition in HCV biomedicine. First generation DAAs in conjunction with interferon were standard of care for most of this time, with the promise of simplified treatment provision on the horizon. FINDINGS Patient accounts of care accentuate the transformative value of interferon-based HCV treatment derived through non-clinical benefits linked to identity and lifestyle change. Such care is constituted as extending beyond the virus and its biomedical effects, with nurse specialists positioned as vital to this care being realised. Provider accounts emphasise the increased pharmaceuticalisation of HCV treatment; whereby care shifts from the facilitation of therapeutic relationships to pharmaceutical access. CONCLUSION HCV care in the interferon-era affords identity transformations for those receiving and providing treatment. Biomedical promise linked to the increasing pharmaceuticalisation of HCV treatment has disruptive potential, shifting how care is practised and potentially the realisation of non-clinical treatment outcomes.
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Affiliation(s)
- Magdalena Harris
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, United Kingdom.
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, United Kingdom
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Harris M, Bonnington O, Harrison G, Hickman M, Irving W. Understanding hepatitis C intervention success-Qualitative findings from the HepCATT study. J Viral Hepat 2018; 25:762-770. [PMID: 29369467 DOI: 10.1111/jvh.12869] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/14/2017] [Indexed: 12/11/2022]
Abstract
The United Kingdom has committed to eliminating viral hepatitis as a public health threat. Innovative interventions for marginalized populations are required to realize this goal. In 2016, the HepCATT study team implemented a complex hepatitis C (HCV) intervention in three English drug treatment services, with five controls. We report qualitative study findings from two intervention sites to explore intervention success and transferability potential. The intervention comprised multiple components, including a nurse facilitator, peer support and education initiatives. Qualitative data were generated at baseline (2014) and post-intervention (2016) at two sites through in-depth interviews, focus groups and observations. The 96 participants comprised drug service and intervention providers and clients with an injecting history. Data were triangulated and thematically analysed. Client engagement with a HCV treatment service rose from 16 at baseline to 147 in 2016. There was no comparable increase at the five control sites. Baseline testing and treatment barriers included the following: limited HCV knowledge; fear of diagnosis and treatment; precarious living circumstances and service-specific obstacles. Treatment engagement was aided by intervention timeliness; improved communication structures; personalized care; streamlined testing and treatment pathways; peer support. Multiple interrelated components influenced the increased levels of treatment engagement documented in HepCATT. The nurse facilitator, involved in implementation and innovation, was key to intervention success. Baseline barriers correspond with international literature-indicating transferability potential. Control data indicate that biomedical innovation alone is not sufficient to increase engagement among the most marginalized. Sustainable resourcing of community services is crucial to effect change.
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Affiliation(s)
- M Harris
- Department of Social and Environmental Health Research, London School of Hygiene, & Tropical Medicine, London, UK
| | - O Bonnington
- Department of Social and Environmental Health Research, London School of Hygiene, & Tropical Medicine, London, UK
| | - G Harrison
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - M Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - W Irving
- Gastrointestinal and Liver Disorders Theme, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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Guise A, Witzel TC, Mandal S, Sabin C, Rhodes T, Nardone A, Harris M. A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK. BMC Infect Dis 2018; 18:281. [PMID: 29914381 PMCID: PMC6006927 DOI: 10.1186/s12879-018-3185-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK. Methods A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses. Results We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation. Conclusions The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.
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Affiliation(s)
- Andy Guise
- London School of Hygiene and Tropical Medicine, London, UK. .,School of Population Health and Environmental Sciences, Guy's campus, King's College London, Addison House, London, UK.
| | - T Charles Witzel
- SIGMA Research, London School of Hygiene and Tropical Medicine, Tavistock Place, London, UK
| | - Sema Mandal
- Public Health England, Wellington House, Waterloo Road, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
| | - Caroline Sabin
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK. .,Institute for Global Health, UCL, London, UK.
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
| | - Anthony Nardone
- Public Health England, Wellington House, Waterloo Road, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in collaboration with Public Health England, London, UK
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Gilchrist G, Swan D, Shaw A, Keding A, Towers S, Craine N, Munro A, Hughes E, Parrott S, Mdege N, Strang J, Taylor A, Watson J. Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial. Health Technol Assess 2017; 21:1-312. [PMID: 29208190 PMCID: PMC5733383 DOI: 10.3310/hta21720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment. OBJECTIVES To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control. DESIGN A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London. SETTING NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016. PARTICIPANTS Current PWID, aged ≥ 18 years. INTERVENTIONS A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control). MAIN OUTCOME MEASURES Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability. RESULTS A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported. CONCLUSIONS As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs. FUTURE WORK The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female. LIMITATIONS Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results. TRIAL REGISTRATION Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gail Gilchrist
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Davina Swan
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - April Shaw
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Sarah Towers
- Betsi Cadwaladr University Health Board, Bangor, UK
| | - Noel Craine
- Public Health Wales, Microbiology, Bangor, UK
| | - Alison Munro
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Elizabeth Hughes
- Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Noreen Mdege
- Department of Health Sciences, University of York, York, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Avril Taylor
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK
| | - Judith Watson
- Department of Health Sciences, University of York, York, UK
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Grebely J, Bruneau J, Lazarus JV, Dalgard O, Bruggmann P, Treloar C, Hickman M, Hellard M, Roberts T, Crooks L, Midgard H, Larney S, Degenhardt L, Alho H, Byrne J, Dillon JF, Feld JJ, Foster G, Goldberg D, Lloyd AR, Reimer J, Robaeys G, Torrens M, Wright N, Maremmani I, Norton BL, Litwin AH, Dore GJ. Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:51-60. [PMID: 28683982 PMCID: PMC6049820 DOI: 10.1016/j.drugpo.2017.05.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 04/11/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | - Julie Bruneau
- CHUM Research Centre (CRCHUM), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Jeffrey V Lazarus
- CHIP, Rigshospitalet, University of Copenhagen, Denmark; Barcelona Institute of Global Health (ISGlobal), Hospital Clínic, Barcelona, Spain
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway; University of Oslo, Oslo, Norway
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | | | - Levinia Crooks
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia; Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, Australia
| | - Håvard Midgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway; Institute for Clinical Medicine, University of Oslo, Norway; Department of Gastroenterology, Oslo University Hospital, Norway
| | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, Australia
| | - Hannu Alho
- University of Helsinki, Helsinki, Finland; National Institute for Health and Welfare, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Jude Byrne
- Australian Injecting & Illicit Drug Users League, Canberra, Australia
| | - John F Dillon
- Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
| | - Graham Foster
- The Liver Unit, Queen Mary University of London, London, United Kingdom
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom; Health Protection Scotland, Glasgow, United Kingdom
| | | | - Jens Reimer
- Centre for Interdisciplinary Addiction Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium; Department of Hepatology, UZ Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Marta Torrens
- Institute of Neuropsychiatry & Addictions-Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Icro Maremmani
- Santa Chiara University Hospital, University of Pisa, Italy
| | - Brianna L Norton
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Alain H Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
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Bonnington O, Harris M. Tensions in relation: How peer support is experienced and received in a hepatitis C treatment intervention. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:221-229. [PMID: 28606391 DOI: 10.1016/j.drugpo.2017.05.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/21/2017] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peer support and involvement is recognised as a vital component of hepatitis C (HCV) treatment provision for marginalised populations, such as people who inject drugs (PWID). Developments in HCV treatments enable increased provision in community settings - expanding the possibilities for meaningful peer involvement in HCV treatment plans. To date, HCV peer support has generally been viewed as a positive intervention, with little critical reflection on the ways social structures, policies, health and drug services and social identity impact on how peer support is experienced and received. METHODS We report on the qualitative component of a UK-based intervention designed to increase HCV diagnosis and treatment in primary care and drug treatment settings. Data were collected between 2014 and 2016. Pre-intervention, a total of 35 PWID clients took part in nine in-depth interviews and four focus groups. In addition, 22 drug services and intervention providers took part in two focus groups and nine interviews. Post-intervention, one focus group and eight interviews were conducted with 13 PWID clients, and four focus groups and ten interviews were conducted with 26 drug services and intervention providers. Our data generation and thematic analysis focused on the peer education and buddy support component of the intervention. RESULTS Participants had common expectations of the peer role (to 'just be there') and its occupants' attributes (empathy, trustworthy, etc.). However, in practice, peers faced constraints on realising these expectations. A 'recovery' dominated drug treatment ethos in the UK appeared to influence the selection of 'recovery champions' as peers for the intervention. This created tensions in relations with clients, particularly when risk-adverse discourses were internalised by the peers. Peers were poorly integrated and supported within the service, affecting opportunities to relate and build trust with clients. Thus, the scope for peer support to impact on the nature and extent of clients' testing and treatment for HCV was limited. CONCLUSION The efficacy of peer involvement can be constrained by organisational structures and boundaries - especially regarding who is deemed to be 'a peer'. Peer programmes take time and care to implement and weave into wider recovery and harm reduction frameworks.
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Affiliation(s)
- Oliver Bonnington
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
| | - Magdalena Harris
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
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Harris M. Managing expense and expectation in a treatment revolution: Problematizing prioritisation through an exploration of hepatitis C treatment 'benefit'. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:161-168. [PMID: 28455145 DOI: 10.1016/j.drugpo.2017.03.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/08/2017] [Accepted: 03/22/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Direct-acting antivirals (DAAs) have transformed the hepatitis C (HCV) treatment landscape. These highly effective drugs are, however, not available to all. In a context of DAA rationing, clinicians are advised to "manage patient expectations" about the benefits of a HCV cure. This directive particularly pertains to people with minimal liver damage and those who have ceased injecting: populations negated in contemporary prioritisation debates. METHODS This paper engages with the assumptions underpinning HCV treatment prioritisation discourses to explore the concept of treatment 'benefit' from patient perspectives. Data are from a qualitative longitudinal study exploring treatment transitions and decision-making from 2012-2015. Participants comprised 28 people living with HCV, ten treatment providers and eight stakeholders, based in London, United Kingdom (UK). One hundred hours of clinic observations were conducted at two HCV treatment hospitals. Thematic analyses pertaining to treatment expectation and outcome inform this paper. RESULTS Twenty-two participants commenced treatment. The majority who were unable to access DAAs chose to commence interferon-based treatment immediately rather than wait. Participants accounted for treatment urgency in relation to three interrelated narratives of hope and expectation. HCV treatment promised: social reconnection; social redemption and a return to 'normality'. For many with successful treatment outcomes, these benefits appeared to be realised. CONCLUSION The DAA era heralds a discursive shift: from 'managing [interferon] risk and difficulty' to 'managing [DAA] expense and expectation'. Calls to 'manage patient expectations' about the benefits of HCV cure are predicated on clinical benefits only, negating the social impacts of living with HCV. The public health priorities commonly articulated in treatment prioritisation debates are not consistent with those of people managing illness in their daily lives. During this 'treatment revolution' there is a need to be cognisant of the multiple publics living with the virus and the treatment needs of those who do not fit population-health scenarios.
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Affiliation(s)
- Magdalena Harris
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H9SH, UK.
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Harm Reduction and Tensions in Trust and Distrust in a Mental Health Service: A Qualitative Approach. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2017; 12:12. [PMID: 28270218 PMCID: PMC5341417 DOI: 10.1186/s13011-017-0098-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 03/01/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND People seeking care for substance use (PSCSU) experience deep social and health inequities. Harm reduction can be a moral imperative to approach these persons. The purpose of this study was to explore relationships among users, health care providers, relatives, and society regarding harm reduction in mental health care, using a trust approach rooted in feminist ethics. METHODS A qualitative study was conducted in a mental health service for PSCSU, and included fifteen participants who were health care providers, users, and their relatives. Individual in-depth and group interviews, participant observation, and a review of patients' records and service reports were conducted. RESULTS Three nested levels of (dis)trust were identified: (dis)trust in the treatment, (dis)trust in the user, and self-(dis)trust of the user, revealing the interconnections among different layers of trust. (Dis)trust at each level can amplify or decrease the potential for a positive therapeutic response in users, their relatives' support, and how professionals act and build innovations in care. Distrust was more abundant than trust in participants' reports, revealing the fragility of trust and the focus on abstinence within this setting. CONCLUSION The mismatch between wants and needs of users and the expectations and requirements of a society and mental health care system based on a logic of "fixing" has contributed to distrust and stigma. Therefore, we recommend policies that increase the investment in harm reduction education and practice that target service providers, PSCSU, and society to change the context of distrust identified.
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Lafferty L, Treloar C, Guthrie J, Chambers GM, Butler T. Social capital strategies to enhance hepatitis C treatment awareness and uptake among men in prison. J Viral Hepat 2017; 24:111-116. [PMID: 27778436 DOI: 10.1111/jvh.12627] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/30/2016] [Indexed: 12/22/2022]
Abstract
Prisoner populations are characterized by high rates of hepatitis C (HCV), up to thirty times that of the general population in Australia. Within Australian prisons, less than 1% of eligible inmates access treatment. Public health strategies informed by social capital could be important in addressing this inequality in access to HCV treatment. Twenty-eight male inmates participated in qualitative interviews across three correctional centres in New South Wales, Australia. All participants had recently tested as HCV RNA positive or were receiving HCV treatment. Analysis was conducted with participants including men with experiences of HCV treatment (n=10) (including those currently accessing treatment and those with a history of treatment) and those who were treatment naïve (n=18). Social capital was a resourceful commodity for inmates considering and undergoing treatment while in custody. Inmates were a valuable resource for information regarding HCV treatment, including personal accounts and reassurance (bonding social capital), while nurses a resource for the provision of information and care (linking social capital). Although linking social capital between inmates and nurses appeared influential in HCV treatment access, there remained opportunities for increasing linking social capital within the prison setting (such as nurse-led engagement within the prisons). Bonding and linking social capital can be valuable resources in promoting HCV treatment awareness, uptake and adherence. Peer-based programmes are likely to be influential in promoting HCV outcomes in the prison setting. Engagement in prisons, outside of the clinics, would enhance opportunities for linking social capital to influence HCV treatment outcomes.
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Affiliation(s)
- L Lafferty
- The Kirby Institute, UNSW Australia, Sydney, NSW, Australia
| | - C Treloar
- Centre for Social Research in Health, UNSW Australia, Sydney, NSW, Australia
| | - J Guthrie
- The Australian National University, Canberra, ACT, Australia
| | - G M Chambers
- National Perinatal Epidemiology and Statistics Unit, UNSW Australia, Sydney, NSW, Australia
| | - T Butler
- The Kirby Institute, UNSW Australia, Sydney, NSW, Australia
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Hawkins EJ, Lott AM, Malte CA, Frank AN, Hamilton B, Sayre GG, Painter JM, Baer JS. Patients' perspectives on care management services for complex substance use disorders. J Addict Dis 2017; 36:193-206. [PMID: 28481144 PMCID: PMC9870041 DOI: 10.1080/10550887.2017.1326654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Although care management approaches have potential to improve clinical outcomes and reduce high health care costs of patients with complex substance use disorders, characterized by high psychosocial, psychological, and/or medical needs and high acute health care utilization, little is known about patients' perspectives or experiences with these interventions. The objectives of this study were to identify barriers and facilitators to patient engagement in care management services for complex substance use disorders from patients' perspectives. This pilot study invited 22 men with complex substance use disorders and high health care utilization who were enrolled in a 1-year open trial of a Care Management Model to complete semi-structured interviews at 1- and 3-months post-baseline. Interviews were recorded, transcribed, and analyzed using template analysis. Five themes related to engagement were identified: barriers to conventional substance use disorder treatment, facilitators of care management services, patient-provider relationship, patient-related factors, and enhancements to a Care Management Model. Results highlighted the importance of the patient-provider relationship, individual visits with providers, flexible and personalized treatment, and a focus on recovery over abstinence in promoting patient engagement in care management services. Results also highlighted a need for increased outreach and assistance with housing and transit to treatment. Patients' perspectives support key elements of the care management services that are designed to facilitate patient engagement and suggest the need for additional outreach and assistance with obtaining shelter and transportation. Additional research is needed to evaluate if care management approaches enhance retention, improve outcomes, and reduce health care utilization of patients with complex and chronic substance use disorders.
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Affiliation(s)
- Eric J. Hawkins
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA,Department of Psychology, University of Washington, Seattle, WA
| | - Aline M.K. Lott
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA
| | - Carol A. Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA
| | - Anissa N. Frank
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA
| | - Brittney Hamilton
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA
| | - George G. Sayre
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Department of Health Services, University of Washington, Seattle, WA
| | | | - John S. Baer
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA,Department of Psychology, University of Washington, Seattle, WA
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Facilitators of HCV treatment adherence among people who inject drugs: a systematic qualitative review and implications for scale up of direct acting antivirals. BMC Public Health 2016; 16:994. [PMID: 27645935 PMCID: PMC5029046 DOI: 10.1186/s12889-016-3671-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/15/2016] [Indexed: 01/16/2023] Open
Abstract
Background While the public health benefits of new HCV treatments depend on treatment adherence, particularly among people who inject drugs (PWID), several social and medical factors can jeopardize treatment adherence. The aim of this study is to examine the qualitative literature on facilitators to HCV treatment adherence among PWID. Methods We searched six databases to identify qualitative research studies on HCV treatment adherence facilitators among PWID. Two reviewers independently extracted and analyzed data using PRISMA guidelines and the CASP tool to evaluate study quality. Results From ten studies representing data from 525 participants, three major themes emerged across studies: logistical facilitators within health systems enhanced HCV treatment adherence, positive social interactions between PWID and staff provided positive feedback during treatment, and HCV treatment may complicate the addiction recovery process. Conclusions Although PWID face several barriers to adherence, we identified treatment adherence facilitators that could be incorporated into clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3671-z) contains supplementary material, which is available to authorized users.
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Chu CE, Wu F, He X, Zhou K, Cheng Y, Cai W, Geng E, Volberding P, Tucker JD. Hepatitis C Virus Treatment Access Among Human Immunodeficiency Virus and Hepatitis C Virus (HCV)-Coinfected People Who Inject Drugs in Guangzhou, China: Implications for HCV Treatment Expansion. Open Forum Infect Dis 2016; 3:ofw065. [PMID: 27419150 PMCID: PMC4943171 DOI: 10.1093/ofid/ofw065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/18/2016] [Indexed: 01/08/2023] Open
Abstract
Background. Hepatitis C virus (HCV) treatment access among human immunodeficiency virus (HIV)/HCV-coinfected people who inject drugs is poor, despite a high burden of disease in this population. Understanding barriers and facilitators to HCV treatment uptake is critical to the implementation of new direct-acting antivirals. Methods. We conducted in-depth interviews with patients, physicians, and social workers at an HIV treatment facility and methadone maintenance treatment centers in Guangzhou, China to identify barriers and facilitators to HCV treatment. We included patients who were in various stages of HCV treatment and those who were not treated. We used standard qualitative methods and organized data into themes. Results. Interview data from 29 patients, 8 physicians, and 3 social workers were analyzed. Facilitators and barriers were organized according to a modified Consolidated Framework for Implementation Research schematic. Facilitators included patient trust in physicians, hope for a cure, peer networks, and social support. Barriers included ongoing drug use, low HCV disease knowledge, fragmented reimbursement systems, HIV exceptionalism, and stigma. Conclusions. Expanding existing harm reduction programs, HIV treatment programs, and social services may facilitate scale-up of direct-acting antivirals globally. Improving integration of ancillary social and mental health services within existing HIV care systems may facilitate HCV treatment access.
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Affiliation(s)
- Carissa E Chu
- School of Medicine, University of California San Francisco; UNC-Project China, Guangzhou
| | - Feng Wu
- School of Sociology and Anthropology, Sun Yat-sen University , Guangzhou
| | - Xi He
- Guangzhou Eighth People's Hospital , China
| | - Kali Zhou
- Guangzhou Eighth People's Hospital , China
| | - Yu Cheng
- School of Sociology and Anthropology, Sun Yat-sen University , Guangzhou
| | | | - Elvin Geng
- School of Medicine, University of California San Francisco
| | | | - Joseph D Tucker
- UNC-Project China, Guangzhou; School of Sociology and Anthropology, Sun Yat-sen University, Guangzhou; Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill
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Harris M, Ward E, Gore C. Finding the undiagnosed: a qualitative exploration of hepatitis C diagnosis delay in the United Kingdom. J Viral Hepat 2016; 23:479-86. [PMID: 26924296 DOI: 10.1111/jvh.12513] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 01/14/2016] [Indexed: 01/31/2023]
Abstract
Hepatitis C virus (HCV)-related morbidity and mortality will continue to rise unless HCV testing and treatment uptake increases. In the European region, an estimated nine million people live with HCV, yet only 10-40% are diagnosed. Over 100 000 undiagnosed people live with HCV in the United Kingdom (UK). For some, a late diagnosis can come too late. The aim of this qualitative study was to explore the context of a diagnosis delay among people living with HCV in the UK. Participants were recruited through two London Hospitals and The Hepatitis C Trust. Eligible participants identified a recent (<3 years) HCV diagnosis and a historical HCV transmission risk period (>15 years). The primary method of data collection was in-depth interviews (12 participants) and focus groups (16 participants). Analysis was informed by grounded theory principles. The sample, 17 men and 11 women, reported an average gap of 28 years between their HCV-risk period and first HCV test. Forty per cent had cirrhosis at HCV diagnosis. Diagnosis delay was attributed to limited HCV relevance, felt wellness, stigma, compartmentalization of former injecting practices, unexplained symptoms and general practitioner inaction. Diagnosis context involved a change of health care providers or a chance medical encounter. Trust in providers was impacted by a delayed diagnosis, with implications for future engagement in care. These data indicate that risk awareness does not necessarily result in action. A multipronged approach is needed to increase HCV case finding in the UK, particularly among 'hidden populations' such as former injectors and transfusion recipients.
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Affiliation(s)
- M Harris
- London School of Hygiene & Tropical Medicine, London, UK
| | - E Ward
- The Hepatitis C Trust, London, UK
| | - C Gore
- The Hepatitis C Trust, London, UK.,The World Hepatitis Alliance, London, UK
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Zamudio-Haas S, Mahenge B, Saleem H, Mbwambo J, Lambdin BH. Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 30:43-51. [PMID: 26880500 PMCID: PMC4829444 DOI: 10.1016/j.drugpo.2016.01.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 01/12/2016] [Accepted: 01/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Strong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT. METHODS We conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment. RESULTS Narratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use. CONCLUSION Expanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use.
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Affiliation(s)
- Sophia Zamudio-Haas
- Department of Preventative Medicine, University of California, 550, 16th Street, San Francisco, CA 94143, United States.
| | - Bathsheba Mahenge
- Department of Psychology, University of Dodoma, P.O. Box 259, Dodoma, Tanzania
| | - Haneefa Saleem
- Pangaea Global AIDS, 436, 14th Street, Suite 920, Oakland, CA 94612, United States
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, P.O. Box 65293, Dar es Salaam, Tanzania
| | - Barrot H Lambdin
- Behavioral and Urban Health Program, RTI International, 351, California St, Suite 500, San Francisco, CA 94104, United States; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, United States; Department of Global Health, University of Washington, Seattle, WA, United States
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Perlman DC, Jordan AE, Uuskula A, Huong DT, Masson CL, Schackman BR, Des Jarlais DC. An international perspective on using opioid substitution treatment to improve hepatitis C prevention and care for people who inject drugs: Structural barriers and public health potential. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1056-63. [PMID: 26050614 PMCID: PMC4581906 DOI: 10.1016/j.drugpo.2015.04.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/28/2015] [Accepted: 04/16/2015] [Indexed: 02/06/2023]
Abstract
People who inject drugs (PWID) are central to the hepatitis C virus (HCV) epidemic. Opioid substitution treatment (OST) of opioid dependence has the potential to play a significant role in the public health response to HCV by serving as an HCV prevention intervention, by treating non-injection opioid dependent people who might otherwise transition to non-sterile drug injection, and by serving as a platform to engage HCV infected PWID in the HCV care continuum and link them to HCV treatment. This paper examines programmatic, structural and policy considerations for using OST as a platform to improve the HCV prevention and care continuum in 3 countries-the United States, Estonia and Viet Nam. In each country a range of interconnected factors affects the use OST as a component of HCV control. These factors include (1) that OST is not yet provided on the scale needed to adequately address illicit opioid dependence, (2) inconsistent use of OST as a platform for HCV services, (3) high costs of HCV treatment and health insurance policies that affect access to both OST and HCV treatment, and (4) the stigmatization of drug use. We see the following as important for controlling HCV transmission among PWID: (1) maintaining current HIV prevention efforts, (2) expanding efforts to reduce the stigmatization of drug use, (3) expanding use of OST as part of a coordinated public health approach to opioid dependence, HIV prevention, and HCV control efforts, (4) reductions in HCV treatment costs and expanded health system coverage to allow population level HCV treatment as prevention and OST as needed. The global expansion of OST and use of OST as a platform for HCV services should be feasible next steps in the public health response to the HCV epidemic, and is likely to be critical to efforts to eliminate or eradicate HCV.
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Affiliation(s)
- David C. Perlman
- Mount Sinai Beth Israel, 120 East 16 Street, 12 Floor, New York, NY, 10003 USA
| | - Ashly E. Jordan
- New York University, 726 Broadway, 10 Floor, New York, NY, 10003 USA
| | - Anneli Uuskula
- Department of Public Health, University of Tartu, Ravila 19, Tartu 50411, Estonia
| | - Duong Thi Huong
- Hai Phong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem, Ngo Quyen, Hai Phong, Socialist Republic of Viet Nam
| | - Carmen L. Masson
- University of California at San Francisco, 1001 Potrero, San Francisco, CA, 94110 USA
| | - Bruce R. Schackman
- Weill Cornell Medical College, 425 East 61 Street, Suite 301, New York, NY 10065 USA
| | - Don C. Des Jarlais
- Mount Sinai Beth Israel, Chemical Dependency Institute, 160 Water Street, 24 Floor, New York, NY 10038, USA
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