A nationwide survey of hepatitis C services provided by drug treatment programs

HCV (Hepatitis C Virus) Pre-Test and Post-Test Counseling Services at Drug Treatment Programs: Missed Opportunities for Primary Prevention

Although drug users are at risk for hepatitis C virus (HCV) infection, many clients in drug treatment programs remain uninformed about their HCV serostatus. Consistent with established Human immunodeficiency virus (HIV) testing and counseling guidelines, recommendations for HCV testing procedures include the delivery of prevention messages targeting all high-risk clients. However, little research has determined whether HCV testing in these programs is accompanied by counseling for HCV antibody negative clients. In this article, we examine staff and client perceptions of pre-test and post-test counseling services at five drug treatment programs in the U.S. Some clients were dissatisfied with pre-test counseling at their programs and some HCV antibody negative clients indicated that they received minimal post-test counseling. Other participants reported that their programs did not offer any post-test counseling for HCV antibody negative clients. Gaps in the pre-test and post-test counseling services at drug treatment programs represent missed opportunities to communicate primary prevention messages to uninfected clients.

Drug Treatment Programs as Sites of Opportunity for the Delivery of Hepatitis C Prevention Education: Client and Staff Perspectives

This paper uses qualitative methods to examine both staff and clients' perceptions about the delivery of hepatitis C prevention education services at their respective residential drug treatment programs. Through in-depth discussion with participants, as well as program observation, we elicited clients' and staff attitudes about the role that drug treatment programs can play in providing prevention education services for hepatitis C, their evaluation of existing hepatitis C prevention education services, and recommendations for enhancing future services. Although participants identified limitations to services, most perceive that treatment programs can play an important role in hepatitis C prevention education service delivery. Participants view clients' misconceptions about hepatitis C, increased disease stigma, and diminished service utilization as potential consequences of limited hepatitis C prevention education services. Recommendations for improving services include more detailed and frequent opportunities for hepatitis C education, formalizing services, offering education in multiple formats, and providing additional staff training.

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

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

Desired social distance from people who have hepatitis C virus: an exploration among staff in health care, dentistry, drug treatment, and tattoo/body piercing

Staff who work in facilities such as health care, dentistry, drug treatment, and tattoo/body piercing are likely to encounter persons with hepatitis C virus (HCV) and be privy to their HCV status. The purpose of this paper is to assess staff comfort with varying levels of intimacy (i.e., social distance) with people who have HCV. We examine how previous contact with persons with HCV and knowledge of HCV including HCV specific training affect desire for social distance. Data are from a 2007 sample of 82 individuals working in health care, dentistry, drug treatment, or tattoo/body-piercing studios located in the Pacific Northwest region of the United States. Multivariate analyses indicate that staff desire social distance from persons with HCV, but contact of certain types reduce desire for social distance. We discuss how the findings have implications for people employed in these fields, as they point to the need to dispel myths and reduce fear among staff working in facilities that may serve persons with HCV.

Factors associated with uptake, adherence, and efficacy of hepatitis C treatment in people who inject drugs: a literature review

INTRODUCTION AND METHODS

Hepatitis C virus (HCV) infections are highly prevalent amongst people who inject drugs (PWID). Despite well documented evidence of its effectiveness, suggested cost-effectiveness, and potential to reduce HCV prevalence rates, the uptake of antiviral HCV treatment by PWID is low. This nonsystematic literature review describes factors associated with the uptake, adherence, and efficacy of HCV treatment among PWID and discusses strategies to increase their uptake of treatment.

RESULTS

Low HCV treatment uptake among PWID is associated with a number of patient-related and provider-related barriers. Beliefs and fears about low efficacy and adverse effects on the patient's part are common. A substantial number of factors are associated with the chaotic lifestyle and altered social functioning of PWID, which are often associated with decompensation or relapsing into drug addiction. This may lead to perceived low adherence with treatment and low efficacy on the provider's part too, where lack of support, inadequate management of addiction, and other drug-related problems and poor treatment of side effects have been described. Practical issues such as the accessibility of treatment and finances also play a role. Strategies to improve the HCV treatment rate among PWID involve pretreatment management and assessment, a multidisciplinary approach, management of side effects, and enhanced education and counseling.

CONCLUSION

Specific factors are associated with poorer treatment outcomes in PWID on the side of both the patient and the treatment system. However, given that PWID can achieve treatment adherence and sustained virologic response rates comparable with those in nondrug users, drug use per se should not be considered a criterion for exclusion from treatment. Further development of measures leading to higher uptake of treatment and adherence in PWID and appropriate adaptation of HCV treatment guidelines represent important tools in this regard.

HIV rapid testing in drug treatment: comparison across treatment modalities

Despite high rates of risky behavior among patients, many drug abuse treatment programs do not provide on-site HIV testing. This secondary analysis examined differences in outcome by program modality from a multi-site trial in which 1281 HIV-negative patients in three methadone programs, seven non-methadone outpatient programs, and three residential programs were randomly assigned to: (1) off-site referral for HIV risk reduction counseling and testing; or on-site rapid testing (2) with or (3) without risk reduction counseling. The parent study using generalized estimating equations with site as a cluster variable found significantly higher rates of HIV testing and feedback of results by 1 month post-enrollment for the combined on-site conditions compared to the offsite condition [RR=4.52, 97.5% CI (3.57, 5.72)]. Utilizing the same statistical approach, we found neither significant treatment modality nor significant treatment modality by testing condition interaction effects either for receipt of HIV test results at 1 month or for sexual or drug use HIV-risk behaviors at 6-month follow-up. On-site HIV testing is effective across treatment modalities for achieving high rates of testing and results feedback. All programs should be encouraged to adopt or expand this service.

How outpatient substance abuse treatment unit director activities may affect provision of community outreach services

Aims

Community outreach services play an important role in infectious disease prevention and engaging drug users not currently in treatment. However, fewer than half of US substance abuse treatment units provide these services and many have little financial incentive to do so. Unit directors generally have latitude about scope of services, including the level of outreach provided to the community. The current study examines how directors' interactions with external stakeholders affect substance abuse treatment units' provision of community outreach services.

Methods

Cross-sectional logistic and Poisson regression analyses were conducted on a national sample of US outpatient substance abuse treatment units (N = 547).

Results

Findings suggest that the amount of time directors spent with licensing and monitoring associations was associated with provision of a greater number of community outreach services, while time spent with professional and occupational associations was associated with provision of off-site human immunodeficiency virus and hepatitis C testing. Several other director attributes and organizational characteristics also emerged as significant.

Conclusions

External stakeholders with whom substance abuse treatment directors interact may influence community outreach through their effects on treatment directors' strategic priorities. Implications for policy and prevention efforts are discussed.

Assessment of methadone clinic staff attitudes toward hepatitis C evaluation and treatment

We used a 25-item, self-administered questionnaire to assess staff's perceived barriers and willingness to engage in onsite treatment of hepatitis C virus (HCV) at the Beth Israel Medical Center methadone maintenance treatment program (MMTP) at its Harlem sites. Of 80 participants, 50% were counselors and 24% were directly involved in referral or HCV testing. Although 92% of the MMTP staff indicated that they discuss HCV evaluation and treatment with patients at least annually, 70% believed that less than 25% of patients accept referral for HCV treatment and attend their initial appointment. Most staff (66%) supported onsite HCV evaluation and treatment, although support was higher among those with a bachelor's degree or higher (p = 0.046). Lack of infrastructure was perceived as the greatest obstacle to onsite treatment. Educational interventions and skill building for staff to confidently engage and support MMTP patients in HCV treatment may be necessary prerequisites for onsite HCV management in MMTPs.

Staff Perspectives on Facilitating the Implementation of Hepatitis C Services at Drug Treatment Programs

Drug users are at risk of acquiring the hepatitis C virus (HCV). Although ancillary services available to clients at drug treatment programs are often limited, some of these programs are providing HCV services. Presenting qualitative data, the authors describe the HCV education and/or support services available at four drug treatment programs and examine staff and client perspectives on factors that facilitated the implementation of these services. Major findings include participants' perceptions that their programs had: (1) at least one change agent on staff who promoted the innovation and delivery of HCV services; (2) at least one administrator or director who encouraged and supported the adoption of these services; and (3) a treatment team that tended to collectively "buy into" and value the HCV service. Ultimately, we found that some drug treatment programs are finding creative and nonresource-intensive ways of delivering HCV services despite the existence of significant barriers. While programs need more funding and resources to overcome these barriers, these findings may prove helpful to other drug treatment programs that would like to offer HCV services to at least some of their clients.

Barriers to providing health services for HIV/AIDS, hepatitis C virus infection and sexually transmitted infections in substance abuse treatment programs in the United States

We sought to identify barriers to offering services for HIV/AIDS, hepatitis C virus, and sexually transmitted infections in substance abuse treatment programs. We surveyed treatment program administrators and clinicians within the National Drug Abuse Treatment Clinical Trials Network to evaluate the availability of medical and non-medical services for patients with or at risk for acquiring these infections. A substantial proportion of programs do not offer services (particularly medical services) for these infections. The most commonly cited barriers were funding, health insurance benefits, patient acceptance, and staff training. The findings highlight a missed opportunity to positively impact these infectious disease epidemics.

Formal patient education improves patient knowledge of hepatitis C in vulnerable populations

BACKGROUND

Hepatitis C (HCV) knowledge is limited in injection drug users (IDU). Vulnerable populations including IDUs are disproportionally affected by HCV. Effective HCV education can potentially reduce disparity in HCV prevalence and its outcome in this population.

AIM

This study aimed to assess the impact of formal HCV education and factors associated with improved HCV knowledge in the vulnerable population.

METHODS

Over 18 months, 201 HCV-infected patients underwent a 2-h standardized education and completed demographic and pre- and post-education questionnaires.

RESULTS

Patient characteristics were: 69% male, mean age 49±10, 49% White (26% AA, 10% Latino), 75% unemployed, 83% high school education and above, 64% were IDU, and 7% were HIV co-infected. On multivariate analysis, baseline knowledge scores were higher in patients with at least a high school education (coef 7.1, p=0.045). Baseline knowledge scores were lower in African Americans (coef -12.3, p=0.004) and older patients (coef -0.7, p=0.03). Following HCV education, the overall test scores improved significantly by 14% (p=0.0001) specifically in the areas of HCV transmission (p=0.003), general knowledge (p=0.02), and health care maintenance (p=0.004). There was a high compliance with liver specialty clinic attendance following education.

CONCLUSIONS

Formal HCV education is effective in improving HCV knowledge. Although White race, younger age, and higher education were predictors of having more HCV knowledge prior to education, all patients independent of racial background had a significant improvement in their knowledge after education. Therefore, promoting effective HCV education among vulnerable populations may be an important factor in reducing the disparities in HCV disease.

Uptake and delivery of hepatitis C treatment in opiate substitution treatment: perceptions of clients and health professionals

Uptake of treatment for hepatitis C virus (HCV) infection is very low particularly among people who have injected drugs. Opiate substitution treatment (OST) programs, with a high prevalence of people living with HCV, have been a site of growing interest in the delivery of hepatitis C treatment. There has been no exploration of OST clients' and health professionals' perceptions of the barriers and facilitators to uptake and delivery of HCV treatment in OST clinics from personal and organizational perspectives. This qualitative study involved interviews with 27 OST clients in New South Wales and a focus group and interviews with 22 Australian OST health professionals. Clients and health professionals viewed hepatitis C treatment in OST as a 'one-stop-shop' model which could increase access to and uptake of treatment and build on existing relationships of trust between OST client and health professional. Elements of the organizational culture were also noted as barriers to HCV treatment delivery including concerns about confidentiality, lack of discussion of HCV treatment and that HCV treatment was not perceived by clinicians as a legitimate activity of OST clinics. OST client participants also reported a number of personal barriers to engaging with HCV treatment including family responsibilities (and concerns about treatment side effects), unstable housing, comorbidities and perceptions of the unsatisfactory level of treatment efficacy. These findings emphasize the need for future research and delivery of services which addresses the complexity of care and treatment for people in marginalized social circumstances.

How persons with chronic hepatitis C in residential substance abuse treatment programs think about depression and interferon therapy

OBJECTIVE

This secondary analysis of existing qualitative descriptive data is the first to specifically report on how persons undergoing residential treatment for substance abuse think about depression and the risks of neuropsychiatric side effects associated with interferon (IFN) treatment for hepatitis C virus (HCV) infection.

METHOD

Krippendorff 's method for qualitative content analysis was used to describe patient perspectives about psychiatric symptoms and potential side effects of IFN treatment. Transcripts from face-to-face, semistructured interviews with 20 patients in 3 residential substance abuse treatment programs were analyzed.

RESULTS

Themes included patients' powerlessness and their evaluation of risk and confidence. Participants commented that residential substance abuse treatment programs offered a unique opportunity to undergo antiviral treatment because they capitalized on a patient's heightened readiness for change. Barriers to treatment included perceived obstacles, such as compulsory waiting periods before treatment initiation, fear that neuropsychiatric treatment side effects would sabotage addiction recovery, and concern that psychiatric providers lacked sufficient HCV knowledge. However, when patients perceived clinicians as knowledgeable and genuinely caring, they were amenable to considering antiviral treatment.

CONCLUSION

Increasing HCV-specific psychiatric education and staff training, exploring combined psychiatric and antiviral treatment combinations, and therapeutically supporting patient decision making are needed to better use substance abuse residential treatment programs as sites for treating HCV infection. Novel antidepressant treatment approaches are required in this population. Advanced practice psychiatric nurses are well-positioned to develop new integrative models of care addressing the medical, psychiatric, and substance abuse comorbidities in this highly vulnerable group.

Research Note: Perspectives on the Hierarchy of HIV and Hepatitis C Disease: Consequences for Drug Treatment Program Patients

Injection drug users (IDUs) face an increased risk of acquiring blood borne viral infections, including HIV and the hepatitis C virus (HCV). However, the discrepancy in funding for services to address these two diseases has implications. Although drug treatment programs have played an important role in fighting HIV/AIDS, the HCV-related services offered at these programs remain limited. Research from other countries suggests that drug users view HCV as less important than HIV, yet little is known about the extent to which our society's focus on HIV has been adopted within the drug treatment program culture. This qualitative study examines the perceptions of both staff (n = 165) and clients (n = 215) at these programs with regard to HIV and HCV and presents data on how staffs' attitudes toward HCV changed after participating in an HCV training. Clients described a services landscape at drug treatment programs that favors HIV services over those targeting HCV.

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

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

Disparities in Health Services for HIV/AIDS, Hepatitis C Virus, and Sexually Transmitted Infections: Role of Substance Abuse Treatment Programs

OBJECTIVES

This report focused upon the availability of infection-related health services in substance abuse treatment programs with and without addiction services tailored for special populations (women and non-white populations).

METHODS

In a cross-sectional, descriptive design, treatment program administrators across the United States within the National Drug Abuse Treatment Clinical Trials Network provided information on program characteristics, the availability of infection-related services (four medical services and three non-medical services for HIV, HCV, and STI), and barriers to providing infection-related services.

RESULTS

Of 319 programs, 269 submitted surveys (84% response rate). Of these, 80% provided addiction services for special populations. Programs providing addiction services designed for at least one special population, were more likely to provide infection-related health services, especially HIV-related education (94% versus 85%, p = 0.05) and patient counseling (76% versus 60%, p = 0.03) and were more likely to include outpatient addiction services (86% versus 57%, p<0.001) and outreach and support services (92% versus 70%, p=0.01). Barriers to providing infection-related services included funding (cited by 48.3% to 74.7% of programs), health insurance (cited by 28.9% to 60.8% of programs), and patient acceptance (cited by 23.2% to 54.3% of programs).

CONCLUSIONS

Despite many barriers, infection-related healthcare is available in programs with addiction treatment services tailored for special populations, especially for African Americans and Latino Americans. Tailoring substance abuse treatment along with reducing barriers to infection-related care represent public health interventions with potential to reduce the burdens and disparities associated with these infections.

Substance abuse treatment clinician opinions and infectious disease service delivery

Substance abuse treatment programs are an important platform for delivery of services for infectious diseases associated with drug and alcohol use. However, important components of infectious disease care are not universally provided. Clinician training often focuses on information about infectious diseases and less attention is paid to provider opinions and attitudes that may be barriers to providing infectious diseases services. In a national multi-site trial conducted by the National Drug Abuse Treatment Clinical Trials Network (CTN), we investigated the relationship between clinician opinions and the delivery of services for human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections in substance abuse treatment settings. Survey data were collected from 1,723 clinicians at 269 CTN treatment programs. Clinician opinion was found to be significantly related to infectious disease service delivery. Implications for training are discussed.

Health services for HIV/AIDS, HCV, and sexually transmitted infections in substance abuse treatment programs

The National Drug Abuse Treatment Clinical Trials Network conducted this study to determine the availability of and factors associated with infection-related health services in substance abuse treatment settings. In a cross-sectional descriptive design, state policies, reimbursement for providers, state level of priority, and treatment program characteristics were studied via written surveys of administrators of substance abuse treatment programs and of state health and substance abuse departments. Data from health departments and substance abuse agencies of 48 states and from 269 substance abuse treatment programs revealed that human immunodeficiency virus/acquired immunodeficiency syndrome-related services are more frequent than hepatitis C virus or sexually transmitted infection-related services, and that nonmedical services are more frequent than medical services. While the availability of infection-related health services is associated with medical staffing patterns, addiction pharmacotherapy services, and state priorities, reimbursement was the most significant determining factor. These findings suggest that greater funding of these health services in substance abuse treatment settings, facilitated by supportive state policies, represents an effective response to the excess morbidity and mortality of these substance use-related infections.

Hepatitis C management by addiction medicine physicians: results from a national survey

Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. We conducted a nationwide survey of American Society of Addiction Medicine physicians (n = 320) to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. We found that substance abuse treatment physicians promote several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment.

HCV and HIV counseling and testing integration in California: an innovative approach to increase HIV counseling and testing rates

OBJECTIVES

In California, injection drug users (IDUs) comprise the second leading risk group for human immunodeficiency virus (HIV) infection and the majority of hepatitis C virus (HCV) cases. Innovative disease screening and prevention activities are needed to improve disease surveillance and to guide appropriate public health responses. This study tested the hypothesis that offering HIV counseling and testing (C&T) concurrently with HCV C&T will increase HIV C&T rates among IDUs.

METHODS

From February through June 2003, HIV and HCV C&T were integrated in five California local health jurisdictions. HIV C&T and disclosure rates among IDUs were monitored when HIV C&T was offered alone during a baseline phase and when offered with HCV C&T during an intervention phase

RESULTS

Among IDUs, HIV C&T rates were significantly higher when HIV and HCV C&T were offered together (27.1%, 354/1,305) than when HIV C&T services were offered alone (8.4%, 138/1,645) (p<0.05). HIV disclosure rates increased from 54.3% (75/138) when only HIV test results were disclosed to 71.8% (254/354) when HIV test results were disclosed concurrently with HCV test results (p<0.05). HCV prevalence among IDUs tested ranged from 23% to 75% at the five project sites. Integrating HIV and HCV C&T increased overall C&T time required for staff and clients and increased stress among counselors due to the number of positive test results (HCV) given to clients.

CONCLUSIONS

Study results suggest that integrating HIV and HCV C&T can increase disease screening rates among IDUs. Careful planning of integrated staff activities and schedules is recommended.

Integrating hepatitis prevention services into a substance use disorder clinic

The Healthy Liver Program, established at the Minneapolis Veterans Affairs Medical Center Substance Use Disorder Clinic, provides screening for exposure to hepatitis infections, a group education class, and an individual nursing appointment to review screening results, give vaccinations for hepatitis A and hepatitis B, and make referrals to the hepatitis clinic as appropriate. A patient chart audit was completed 11 months after the establishment of the Healthy Liver Program. The attendance rate for the educational group and individual feedback sessions was 66.9%, with 94.1% of attendees accepting recommended hepatitis A and/or hepatitis B vaccinations. All patients with chronic hepatitis C who attended the Healthy Liver Program received a referral for evaluation in the hepatitis clinic, as compared with only 50% of patients with chronic hepatitis C who were identified before the establishment of the program. The importance of providing comprehensive educational sessions and recommendations for how patients with substance use disorders can access hepatitis screening, vaccination, and treatment resources are stressed.

Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services

Background

In spite of the disproportionate prevalence of hepatitis C virus (HCV) infection among drug users, many remain uninformed or misinformed about the virus. Drug treatment programs are important sites of opportunity for providing HCV education to their patients, and many programs do, in fact, offer this education in a variety of formats. Little is known, however, about the level of HCV knowledge among drug treatment program patients, and the extent to which they utilize their programs' HCV education services.

Methods

Using data collected from patients (N = 280) in 14 U.S. drug treatment programs, we compared patients who reported that they never injected drugs (NIDUs) with past or current drug injectors (IDUs) concerning their knowledge about HCV, whether they used HCV education opportunities at their programs, and the facilitators and barriers to doing so. All of the programs were participating in a research project that was developing, implementing, and evaluating a staff training to provide HCV support to patients.

Results

Although IDUs scored higher on an HCV knowledge assessment than NIDUs, there were many gaps in HCV knowledge among both groups of patients. To address these knowledge gaps, all of the programs offered at least one form of HCV education: all offered 1:1 sessions with staff, 12 of the programs offered HCV education in a group format, and 11 of the programs offered this education through pamphlets/books. Only 60% of all of the participating patients used any of their programs' HCV education services, but those who did avail themselves of these HCV education opportunities generally assessed them positively. In all, many patients were unaware that HCV education was offered at their programs through individual sessions with staff, group meetings, and books/pamphlets, (42%, 49%, and 46% of the patients, respectively), and 22% were unaware that any HCV education opportunities existed.

Conclusion

Efforts especially need to focus on ensuring that all drug treatment program patients are made aware of and encouraged to use HCV education services at their programs.

Follow-up for medical care among drug users with hepatitis C

Prevalence of hepatitis C (HCV) in injection drug users (IDUs) is high and once HCV has been detected, follow-up medical care is essential. Six hundred and one current and former IDUs who tested positive for HCV antibodies received referrals for medical care. Twenty-four percent (147) of participants returned to be interviewed regarding their medical follow-ups. Of these, only 42% (61) had sought additional medical care in the form of further liver or blood tests or liver ultrasound. Four variables predicted seeking medical care: (a) ever being in residential drug treatment, (b) ever trading sex for money, (c) self-reported homelessness, and (d) living in one's own apartment or house. Having income from a job was inversely associated with seeking medical care. Knowledge of HCV infection alone does not mean that IDUs will seek medical care. Additional education concerning medical care and treatment options are needed to address IDU needs.

Characteristics of substance abuse treatment programs providing services for HIV/AIDS, hepatitis C virus infection, and sexually transmitted infections: the National Drug Abuse Treatment Clinical Trials Network

Illicit drug users sustain the epidemics of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hepatitis C (HCV), and sexually transmitted infections (STIs). Substance abuse treatment programs present a major intervention point in stemming these epidemics. As a part of the "Infections and Substance Abuse" study, established by the National Drug Abuse Treatment Clinical Trials Network, sponsored by National Institute on Drug Abuse, three surveys were developed; for treatment program administrators, for clinicians, and for state and District of Columbia health and substance abuse department administrators, capturing service availability, government mandates, funding, and other key elements related to the three infection groups. Treatment programs varied in corporate structure, source of revenue, patient census, and medical and non-medical staffing; medical services, counseling services, and staff education targeted HIV/AIDS more often than HCV or STIs. The results from this study have the potential to generate hypotheses for further health services research to inform public policy.

Medical examinations at entry to treatment for drug abuse as an opportunity to initiate care for hepatitis C virus infection

Over the course of addiction, a substantial proportion of drug users enter drug abuse treatment programs. Data from a cross-sectional survey of drug abuse treatment programs in the United States were analyzed to describe the scope of the medical examination performed at admission to such programs. All of the methadone programs (n=95) and 50% of drug-free programs (80 of 161) required a medical examination at entry. Most examinations included screening for signs and symptoms of liver disease and liver function testing. Nearly all methadone programs (97%) provided referral to medical care or support for patients with test results positive for antibody to hepatitis C virus (HCV), compared with 75% of drug-free programs (P<.01). Drug-free programs requiring medical examinations provided education about HCV and testing for HCV to a larger proportion of their patients (P<.05). With high dropout rates in the early stages of treatment for drug addiction, these medical visits may be an important opportunity for further monitoring and care for HCV infection and other conditions.

Using latent class analysis to identify patterns of hepatitis C service provision in drug-free treatment programs in the U.S

Hepatitis C virus (HCV) infection is a global health problem, and in many countries (including the U.S.), illicit drug users constitute the group at greatest risk for contracting and transmitting HCV. Drug treatment programs are therefore unique sites of opportunity for providing medical care and support for many HCV infected individuals. This paper determines subtypes of a large sample of U.S. drug-free treatment programs (N=333) according to services they provide to patients with HCV infection, and examines the organizational and aggregate patient characteristics of programs in these subtypes. A latent class analysis identified four subtypes of HCV service provision: a "Most Comprehensive Services" class (13% of the sample), a "Comprehensive Off-Site Medical Services" class (54%), a "Medical Monitoring Services" class (8%) and a "Minimal Services" class (25%). "Comprehensive" services class programs were less likely to be outpatient and private for profit than those in the other two classes. It is of concern that so many programs belong to the "Minimal Services" class, especially because some of these programs serve many injection drug users. "Minimal Services" class programs in the U.S. need to innovate services so that their HCV infected patients can get the medical and support care they need. Similar analyses in other countries can inform their policy makers about the capacity of their drug treatment programs to provide support to their HCV infected patients.

Hepatitis C knowledge among staff in U.S. drug treatment programs

Staff in drug treatment programs are in an optimal position to support the hepatitis C related needs of their patients. To do so effectively, however, staff need to have accurate information about the hepatitis C virus (HCV). This article examines the HCV knowledge of staff (N= 104) in two drug-free and two methadone maintenance treatment programs (MMTPs) in the New York metropolitan area. Five of 20 items on an HCV Knowledge Assessment were not answered correctly by the majority of the participating staff, and total scores on the Assessment averaged 70%, 71%, and 45% among the medically credentialed staff, non-medically credentialed staff in the MMTPs, and non-medically credentialed staff in the drug-free programs, respectively. The majority of those in the latter group had never participated in a training specifically devoted to HCV. Results suggest the need for effective HCV-related training for all staff in drug treatment programs.

Knowledge of and interest in hepatitis C treatment at a methadone clinic

This study describes knowledge about hepatitis C virus (HCV) infection and interest in treatment among 110 opiate dependent patients from an opiate dependence treatment program in San Francisco. None had been treated for HCV and only 30% had been evaluated for HCV treatment. While only 34% knew about HCV treatment, 54% of the sample became "definitely interested" in HCV treatment after hearing the risks and benefits. Men were approximately five times more likely than women to know of some HCV treatment. Whites were seven times and Latinos were about six times more likely than African-Americans to know about HCV treatment. Our findings suggest that methadone programs can play an important role in increasing access to HCV treatment through educating patients about treatment options.

Integrated hepatitis C virus treatment: addressing comorbid substance use disorders and HIV infection

OBJECTIVES

To examine hepatitis C virus (HCV) and HIV testing patterns within the Northwest Veterans Integrated Service Network (VISN 20).

METHODS

Using a comprehensive VISN 20 database, we retrospectively reviewed medical records of 293,445 veterans.

RESULTS

32.8% of patients were tested for HCV, 5.5% were tested for HIV, and 4.3% were co-tested. Of those tested, 12.3% were HCV positive, 5.4% were HIV positive, and 1.6% were co-infected. 79.1% of HIV-positive patients were tested for HCV, 29.2% of whom tested positive. 34.8% of HCV-positive patients were tested for HIV, 4.9% of whom tested positive. Of those tested, HCV-positive patients were significantly more likely than HCV-negative patients to test positive for HIV; HIV-positive patients were no more likely to test positive for HCV than HIV-negative patients. HIV-positive patients with substance use disorders (SUD) were significantly more likely to test HCV positive than those without. Within the total sample, veterans with SUD were significantly more likely to be tested for both diseases and to test positive for HCV but not HIV. After controlling for other categories of SUD, veterans with a history of cocaine abuse compared with those without were at an increased risk of HIV infection and co-infection.

CONCLUSION

79.1% of HIV-positive but only 34.8% of HCV-positive veterans were co-tested, suggesting barriers to HIV testing may exist in VISN 20. Results also indicate that HCV-positive patients are at increased risk for HIV infection and that HIV-positive patients with SUD are at increased risk of HCV infection; routine co-testing for these patients is therefore warranted. Given significant co-infection rates, HCV and HIV screening and testing should be increasingly integrated. Increased infection rates among patients with SUD also warrant integration of HCV and HIV screening and testing into mental health and addiction programmes.

HIV/hepatitis C virus co-infection in drug users: risk behavior and prevention

Studies of HIV-positive patients have consistently shown that drug users, in particular injection drug users (IDU), are far more likely to have hepatitis C virus (HCV) infection than other patient groups. HIV incidence and prevalence in IDU has declined in recent years, but HCV remains endemic in this population. HCV antibody prevalence among non-injection users of drugs such as heroin and cocaine is between 5 and 30%, although there are scant data on specific transmission risk behavior. The control of HIV/HCV co-infection must address HCV prevention. Epidemiological studies have suggested that HCV prevalence in IDU is subject to various influences, some of which may be modifiable by interventions. However, studies have not shown consistent effects of various prevention strategies on HCV transmission, including studies of HCV screening and education, drug treatment or needle exchange. Although some large cross-sectional studies in regions where needle exchange is available to a large number of drug injectors have reported declining HCV prevalence, the scale of services needed is a matter of considerable debate and has not been systematically quantified. Priorities for research related to the prevention of HIV/HCV co-infection should include estimating the effect on disease occurrence of eliminating specific risk factors, and specifying the level of resources needed to alter HCV incidence.

Integrating hepatitis, STD, and HIV services into a drug rehabilitation program

BACKGROUND

Considering the difficulties in providing screening and vaccination services for inmates in short-stay incarceration facilities, an evaluation was conducted of the integration of prevention services in an alternative sentencing drug rehabilitation program (alternative to incarceration) in San Diego CA.

METHODS

During the period April 1999 to December 2002, clients were asked to complete a brief risk-assessment questionnaire, and were offered hepatitis B virus (HBV) vaccination, HBV and hepatitis C virus (HCV) serologic testing, STD screening, and HIV counseling and testing.

RESULTS

Of the estimated 1125 rehabilitation program enrollees, 930 (83%) participated in the integration program services. Most clients were male (64%), were aged >30 years (64%), and few (7%) reported previous HBV vaccination. Of the 854 clients eligible for hepatitis B vaccination, 98% received the first dose, 69% the second dose, and 42% completed the series. Eleven percent of clients had prior HBV infection, and 14.7% had HCV infection, with positivity rates being highest among those with a history of injection drug use-HBV, 19%, and HCV, 36%. HIV infection was rare (prevalence, 0.3%), and STDs were uncommon (chlamydia prevalence, 2%, and gonorrhea prevalence, 0.6%). Total annual cost of integration services (excluding HIV testing) was dollar 31,994 equating to dollar 122 per client served.

CONCLUSIONS

Alternative sentencing drug rehabilitation programs provide a venue to efficiently deliver integrated hepatitis and other prevention services. Considering the vast number of high-risk persons in drug rehabilitation, probation, parole, and inmate release programs, an opportunity exists to greatly expand hepatitis services.

Outpatient drug treatment program directors' hepatitis C-related beliefs and their relationship to the provision of HCV services

The hepatitis C virus (HCV) continues to penetrate populations within the United States, especially within the drug-abusing population. Therefore, drug users need access to HCV testing and medical care, and drug treatment programs are well situated to provide these services. Because directors of these programs are gatekeepers who can influence decisions about service provision, their beliefs about the value of providing particular services for drug treatment program patients are of considerable importance. Directors of 121 outpatient drug treatment programs throughout the United States responded to an in-depth telephone survey that included questions on their beliefs about providing HCV services in drug treatment programs. We constructed an eight-item scale to examine these beliefs and investigated the relationship between them and the actual HCV services offered. Overall, directors were moderately supportive of the provision of HCV medical services (on-site or through referral) during drug treatment. Our findings indicate that there is a positive significant relationship between director's beliefs and the provision of HCV antibody testing, follow-up testing, and the provision of HCV medication.

Integrating hepatitis C services into existing HIV services: the experiences of a sample of U.S. drug treatment units

Hepatitis C virus (HCV) is the most prevalent blood-borne infectious disease in the United States, especially among drug users, and coinfection with HIV is common. Because drug users are often medically underserved, drug treatment units are important sites of opportunity for providing services for these infectious diseases. Given the commonalities in the routes of transmission of HIV and HCV, and the fact that many drug treatment units have established an infrastructure to provide HIV services, some have suggested integrating HCV services into those already established for HIV. Using data collected in a telephone survey with 89 drug treatment units throughout the United States, this paper examines the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV- and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number of these units, however, indicated that having an HIV service infrastructure did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Policy makers and individual treatment units need to develop strategies that capitalize on existing infrastructures while maintaining the distinction between HIV and HCV primary and secondary prevention efforts.

Hepatitis C Virus Infection Among Injection Drug Users

BACKGROUND

Time to hepatitis C virus (HCV) seroconversion in initially seronegative injection drug users has not been directly measured, and public health planning would benefit from specifying the window of opportunity for prevention of infection, and factors that affect timing of infection.

METHODS

Four hundred eighty-four HCV antibody-negative injection drug users in Seattle, Washington were followed a median of 2.1 years to observe seroconversion. We examined time to HCV seroconversion in relation to subject characteristics using the Kaplan-Meier method and Cox proportional hazards regression. A weighted-average time to HCV seroconversion was calculated among new injectors (injecting < or = 2 years) using seroprevalence and seroincidence data.

RESULTS

There were 134 HCV seroconversions (11.6 per 100 person-years at risk; the 25th percentile of time to seroconversion was 26.2 months). Injection with a syringe used by another injector (adjusted hazards ratio = 1.8; 95% confidence interval = 1.3-3.0) and sharing a cooker or cotton (1.8; 1.0-3.1) were associated with time to HCV seroconversion. Using the estimate of the mean time to seroconversion from first injection in new injectors who were HCV antibody-negative at enrollment (5.4 years), and the midpoint between first injection and study enrollment in new injectors who were HCV antibody-positive at enrollment (0.6 years), the weighted-average time to seroconversion after beginning to inject was estimated to be 3.4 years.

CONCLUSION

The period of susceptibility to HCV infection in the majority of drug injectors appears to be long enough to justify the allocation of substantial resources toward interventions to reduce injection-related risk behavior in these individuals.

Injection drug users and the provision of hepatitis C-related services in a nationwide sample of drug treatment programs

Drug treatment facilities are important sites for providing targeted prevention and health services to injection drug users (IDUs) who are infected with the hepatitis C virus (HCV). A nationwide survey was conducted to examine whether differences exist in the HCV-related services provided by drug treatment programs that have varying proportions of IDUs among their patients. The results indicate that, overall, drug treatment programs with a greater proportion of IDUs offer significantly more HCV services as compared to programs with a smaller proportion of IDUs. However, important components of hepatitis C-related care, such as universal basic education and counseling about HCV and extensive HCV-antibody testing, are not yet being provided by all programs with a large proportion of IDUs among their patient populations.

The content and comprehensiveness of hepatitis C education in methadone maintenance and drug-free treatment units

Although drug users are at elevated risk for hepatitis C virus (HCV) infection, many are uniformed or misinformed about the virus. Drug treatment programs are uniquely situated to provide comprehensive risk-modifying educational programs for decreasing HCV transmission, a strategy advocated in the most recent National Institutes of Health Consensus Development Conference Statement on the Management of Hepatitis C. Given the large proportion of patients that inject drugs in methadone maintenance treatment programs and the high prevalence of HCV among drug injectors, we compared a nationwide sample (N = 246) of methadone maintenance treatment programs and drug-free programs regarding the content and comprehensiveness of HCV education. All of these programs provide HCV education to at least some of their patients. Results indicated that, compared to drug-free programs, methadone maintenance treatment programs cover a significantly greater number of HCV-related topics, and that a significantly greater proportion of the methadone programs cover specific topics (e.g., how to avoid transmitting HCV, the importance of testing for HCV, treatment options if HCV positive). Of special concern is that fewer than three quarters of the drug-free programs address what to do if co-infected with human immunodeficiency virus (HIV) and HCV and how to maintain health if HCV positive, and only about half of the drug-free and methadone maintenance treatment programs educate HCV-positive patients about the importance of obtaining vaccinations for hepatitis A and B. Drug treatment programs need to educate patients about the proactive steps these individuals can take to deal with HCV, provide critically needed HCV services, and encourage patients to make full use of these services.

Gaps in the drug-free and methadone treatment program response to Hepatitis C

Drug treatment programs are sites of opportunity for the delivery of hepatitis C (HCV) prevention and care services to drug users. Using data collected from a random nationwide sample (N = 595) of drug treatment programs in the United States, this study compares the provision of HCV services by drug-free and methadone maintenance treatment programs (MMTPs). It then examines and compares perceived inadequacies in this service provision from the perspective of the managers in these two types of programs. Findings indicate that MMTPs are providing more HCV services to their patients, and that a greater proportion of MMTPs are dissatisfied with their current level of HCV service provision. Managers of drug-free programs would like to be offering patients more HCV education, while MMTP managers would like to be providing more HCV testing to their patients, and more support and care for patients who are HCV+.

Provision of hepatitis C education in a nationwide sample of drug treatment programs

Hepatitis C virus (HCV) has reached epidemic proportions among drug users, and drug programs are in a unique position to provide each of their patients with HCV education. Using a nationwide sample (N = 434) of drug treatment programs, we report the results of a logistic regression analysis that differentiates programs providing HCV education to all of their patients versus programs that do not. Fifty-four percent of the programs provide HCV education to all of their patients. Programs are about four and a half times as likely to provide HCV education to all patients if they dispense methadone; almost four times as likely to provide this service if they educate most of their staff about HCV; twice as likely if they are residential; and almost twice as likely if they conduct HIV testing on-site. Our findings indicate that there is a need to increase HCV educational services in drug treatment programs.