Hepatitis C testing and injecting risk behaviour: the results of a UK based pilot study

Strategies to achieve population control of HCV infection: results of a multidisciplinary focus group

BACKGROUND

To meet the World Health Organization's ambitious target to eradicate hepatitis C virus (HCV) by 2030, a comprehensive strategy is needed in Canada to ensure everyone infected with HCV is identified, diagnosed, and treated. The purpose of this study was to highlight the barriers to any strategy aimed at achieving this goal.

METHODS

A focus group was formed (N = 11) that consisted of clinicians, patients, drug program budget managers, industry representatives, and individuals from provincial public health and federal agencies in Canada. The group met in person for a half-day focus group session. Two discussions were held: one on future barriers related to HCV treatment and one related to HCV screening. A grounded theory approach was used to elicit key themes from the day's discussion.

RESULTS

Nine themes were identified. Four themes related to HCV screening: public awareness and engagement, resource infrastructure and capacity, heterogeneity between provinces, and mechanisms of screening. Three themes related to HCV treatment: access to treatment and illicit drug use, linkage to care, and predicting post-treatment outcomes. Two overarching themes that contributed to most discussions were a focus on baby boomers versus persons who inject drugs and the need for further education and training.

CONCLUSION

The views and findings extracted from this qualitative research complement proposals of national strategies from organizations such as the Canadian Network on Hepatitis C. This work highlights the financial, logistical, and ethical constraints that need to be tackled to make HCV elimination proposals a reality.

Understanding hepatitis C intervention success-Qualitative findings from the HepCATT study

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.

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.

HIV Risk Perception and Risky Behavior Among People Who Inject Drugs in Kermanshah, Western Iran

PURPOSE

Understanding and increasing awareness on individual risk for HIV infection as well as HIV risk perception's effects on different behavioral outcomes for people who inject drugs (PWID) is important for policymaking and planning purposes. The objectives of the present study were to determine whether HIV risk perception was associated with greater injection and sexual risk-taking behaviors among PWIDs.

METHOD

We surveyed 460 PWID in Kermanshah regarding their demographic characteristics, sexual risk behaviors, HIV risk perception, and drug-related risk behaviors in the month prior to the study. Three classes of HIV risk perception were identified using ordinal regression to determine factors associated with HIV risk perception.

RESULTS

Study participants were categorized as follows: "low" (n = 100, 22%), "moderate" (n = 150, 32%), and "high" (n = 210, 46%) risk perception for becoming infected with HIV. The odds of categorizing as "high" risk for HIV was significantly greater in PWID that reported unprotected sex (adjusted odds ratio (AOR) 2.4, p value 0.02), receptive syringe sharing (AOR 1.8, p value 0.01), and multiple sex partners (AOR 1.4, p value 0.03). PWID who reported unprotected sex had 2.7 times the odds of "high" risk perception when compared to PWID with "low" risk perception.

CONCLUSION

Findings show that PWID could rate their HIV risk with acceptable accuracy. Additionally, perceived HIV risk was associated with many risk factors for transmission of HIV, emphasizing the importance of developing targeted prevention and harm reduction programs for all domains of risk behaviors, both sexual and drug-related use.

Views and experiences of hepatitis C testing and diagnosis among people who inject drugs: systematic review of qualitative research

BACKGROUND

Many developed countries are facing a major challenge to improve identification of individuals acutely and chronically infected with hepatitis C virus (HCV) infection. We explored the views and experiences of people who inject drugs (PWID) in relation to HCV testing, and diagnosis through a review and synthesis of qualitative research.

METHODS

Based on the thematic synthesis of qualitative research. Searches were conducted in 14 databases and supplemented by reference checking, hand searching of selected journals, and searches of relevant websites. Studies of any qualitative design that examined the views and experiences of, and attitudes towards, HCV testing and diagnosis among PWID or practitioners involved in their care were included. Key themes and sub-themes were systematically coded according to the meaning and content of the findings of each study which proceeded to the preparation of a narrative account of the synthesis.

RESULTS

28 qualitative studies were identified. We identified a number of overarching descriptive themes in the literature, finding overall that PWID hold complex and differing views and experiences of testing and diagnosis. Three major themes emerged: missed opportunities for the provision of information and knowledge; shifting priorities between HCV testing and other needs; and testing as unexpected and routine. Evidence of missed opportunities for the provision of knowledge and information about HCV were clear, contributing to delays in seeking testing and providing a context to poor experiences of diagnosis. Influenced by the nature of their personal circumstances, perceptions of the risk associated with HCV and the prioritisation of other needs acted both to encourage and discourage the uptake of HCV testing. Undergoing HCV testing as part of routine health assessment, and an unawareness of being testing was common. An unexpected positive diagnosis exacerbated anxiety and confusion.

CONCLUSION

This review has identified that there are modifiable factors that affect the uptake of HCV testing and experiences of HCV diagnosis among PWID. Intervention development should focus on addressing these factors. There is a need for further research that engages PWID from a diverse range of populations to identify interventions, strategies and approaches that they consider valuable.

Does informing people who inject drugs of their hepatitis C status influence their injecting behaviour? Analysis of the Networks II study

BACKGROUND

People who inject drugs (PWID) are at risk of hepatitis C virus (HCV). It is plausible that PWID who receive a diagnosis of HCV will reduce their injecting risk out of concern for their injecting partners, although evidence for this is currently limited. The aim of this study was to investigate whether informing PWID of their HCV diagnosis was associated with a change in injecting behaviour.

METHODS

Prospective, longitudinal study of PWID recruited from street drug markets across Melbourne, Australia. Interviews and HCV testing were conducted at 3-monthly intervals. The association between receiving a diagnosis of HCV and (i) injecting frequency and (ii) injecting equipment borrowing, was examined using generalized estimating equations (GEE) analysis.

RESULTS

Thirty-five individuals received a diagnosis of HCV during the study period. Receiving a diagnosis of HCV was associated with a decrease of 0.35 injections per month (p=0.046) but there was no change in injecting equipment borrowing (p=0.750).

CONCLUSIONS

A small reduction in injecting frequency was observed in PWID who received a diagnosis of HCV. This finding should be investigated further in larger studies examining a wider range of injecting risk behaviours.

Strategies to avoid opiate withdrawal: implications for HCV and HIV risks

BACKGROUND

Research on heroin withdrawal has primarily been done clinically, thus focussing on symptom severity, physiological manifestations, and how withdrawal impairs normal functioning. However, there is little scientific knowledge on how heroin withdrawal affects injection behaviour. This paper explores how withdrawal episodes heighten unsafe injection practices and how some long-term injectors manage such risks.

METHODS

We interviewed 32 injection drug users in New York City who had been injecting drugs for 8-15 years (21 HIV and HCV uninfected; 3 HIV and HCV infected; and 8 singly infected with HCV). We used in-depth life history interviews to inquire about IDUs' life history, injection practices and drug use behaviour over time. Analysis used grounded theory techniques.

RESULTS

Withdrawal can enhance risk by undermining IDUs' willingness to inject safely; increasing the likelihood of attending risky settings; raising the number of injection partners; and seeking ad hoc partners for drug or needle sharing. Some IDUs have developed practices to cope with withdrawal and avoid risky practices (examples include carrying clean needles to shooting galleries and sniffing rather than injecting). Strategies to avoid withdrawal include back up methods, resorting to credit, collaborating with others, regimenting drug intake, balancing drug intake with money available, and/or resorting to treatment.

CONCLUSION

Withdrawal periods can heighten risky injection practices. Some IDUs have applied strategies to avoid withdrawal or used practices to cope without engaging in risky practices. These behaviours might in turn help IDUs prevent an infection with hepatitis C or HIV.

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

INTRODUCTION AND AIMS

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

DESIGN AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSIONS

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

The lived experience of hepatitis C and its treatment among injecting drug users: qualitative synthesis

Hepatitis C virus infection is a stigmatized condition because of its close association with injecting drug use. There is a need to explore how people who inject drugs (IDUs) perceive hepatitis C, including in relation to treatment experience. We undertook a review, using a qualitative synthesis approach, of English-language qualitative research focusing on the lived experience of hepatitis C among IDUs. The review included 25 published articles representing 20 unique studies. A synthesis of this literature generated three interplaying themes: social stigma, biographical adaptation, and medical and treatment encounters. Interactions with health systems can reproduce stigma linked to drug injecting and hepatitis C, as well as trivialize the lived experience of diagnosis and illness. Hepatitis C can be biographically reinforcing of socially accommodated risk and spoiled identity, as well as disruptive to everyday life. We hypothesize hepatitis C as a liminal illness experience, oscillating between trivial and serious, normalized and stigmatized, public and personal. We conclude by emphasizing the disconnects between the lived experience of hepatitis C among IDUs and Western health care system responses.

Access to sterile injecting equipment is more important than awareness of HCV status for injection risk behaviors among drug users

Awareness of hepatitis C virus (HCV) infection status is expected to influence risk behaviors. In 2004-2005, injection drug users (IDUs) recruited from syringe exchange programs (SEPs) and methadone clinics in Montreal, Canada, were interviewed on drug use behaviors (past 6 months) and HCV testing. Subjects (n = 230) were classified as low/intermediate risk (20.4% borrowed drug preparation equipment only) and high risk (19.6% borrowed syringes), and 54.5% reported being HCV positive. Logistic regression modeling showed that compared to no risk (60% borrowed nothing), low/intermediate risk was associated with fewer noninjecting social network members, poor physical health, and problems obtaining sterile injecting equipment. High risk was associated with all of these factors except social networks. HCV status was not associated with any level of risk. Improved access to sterile injecting equipment may be more important than knowledge of HCV status in reducing injection risks among this IDU population. The study limitations are noted and recommendations discussed.

The social production of hepatitis C risk among injecting drug users: a qualitative synthesis

BACKGROUND

Intervention impact on reductions in hepatitis C virus (HCV) incidence among injecting drug users (IDUs) are modest. There is a need to explore how drug injectors' interpret HCV risk.

AIMS

To review English-language qualitative empirical studies of HCV risk among IDUs.

METHODS

Qualitative synthesis using a meta-ethnographic approach. Searching of eight electronic databases and reference lists identified manually papers in peer-reviewed journals since 2000. Only studies investigating IDU perspectives on HCV risk were included. Themes across studies were identified systematically and compared, leading to a synthesis of second- and third-order constructs.

FINDINGS

We included 31 papers, representing 24 studies among over 1000 IDUs. Seven themes were generated: risk ubiquity; relative viral risk; knowledge uncertainty; hygiene and the body; trust and intimacy; risk environment; and the individualization of risk responsibility. Evidence supports a perception of HCV as a risk accepted rather than avoided. HCV was perceived largely as socially accommodated and expected, and in relative terms to human immunodeficiency virus (HIV) as the 'master status' of viral dangers. Symbolic knowledge systems, rather than biomedical risk calculus, and especially narratives of hygiene and trust, played a primary role in shaping interpretations of HCV risk. Critical factors in the risk environment included policing, homelessness and gendered risk.

CONCLUSIONS

Appealing to risk calculus alone is insufficient. Interventions should build upon the salience of hygiene and trust narratives in HCV risk rationality, and foster community changes towards the perceived preventability of HCV. Structural interventions in harm reduction should target policing, homelessness and gendered risk.

Hepatitis C virus (HCV) prevalence, and injecting risk behaviour in multiple sites in England in 2004

We sought to corroborate geographical differences in hepatitis C virus (HCV) prevalence and assess whether these can be explained by differences in injecting risk behaviour. A community recruited interview survey of 1058 injecting drug users (IDU) - including a blood spot specimen for antibody testing - was undertaken in seven cities in England. HCV prevalence varied from 27% to 74% across sites (chi(2)(6) = 115.3, P < 0.001). There was a significant variation in crack-injection, prison history, injecting frequency, homelessness, groin injecting, syringe reuse and sharing between the sites. Adjustment for clustering by site and other covariates attenuated the odds ratios (OR) for most variables: e.g. crack injection changed from an unadjusted OR of >2 to an adjusted OR of 1.4 (95% CI 0.9-2.0). Remaining significant covariates included: homelessness (OR 2.2; 1.4-3.6); ever imprisonment (OR 1.7; 1.2-2.5); syringe sharing >18 months ago (OR 2.0; 1.3-3.0); injecting duration and age. Introducing site as a second level variable did not reach significance (P = 0.10). HCV prevalence among IDU reporting 'never sharing' was 48%. Geographical variation in HCV prevalence remains poorly explained, but should be the key focus of our surveillance effort. Measures of sharing and their interpretation require greater scrutiny.

Perceived barriers to safe-injection practices among drug injectors who remain HCV-negative

Fifty-nine hepatitis C (HCV) seronegative drug injectors (IDUs) were interviewed regarding their injection equipment sharing behaviors. Participants were 75% male, 66% Caucasian, had injected an average of nine years, and were very knowledgeable about HCV transmission risk. One-third used needles or works after another injector within the past six months. Lower perceived personal risk and lower perceived availability of clean needles were significantly associated with sharing. Injectors were more likely to share when emotionally upset or experiencing withdrawal symptoms. Despite, or perhaps because of, their HCV seronegative status, IDUs continue to share. Tailoring messages to modifiable perceptions of risk may be useful in reducing continued drug equipment sharing.

'I just keep thinking I haven't got it because I'm not yellow': a qualitative study of the factors that influence the uptake of Hepatitis C testing by prisoners

BACKGROUND

Hepatitis C viral (HCV) infection is a significant public health problem. In the UK, an estimated 200,000 individuals have active HCV infection, most of whom are injecting drug users (IDUs). Many IDUs spend time within the prison system therefore screening for HCV infection in this setting is important. However, uptake of testing within prisons is very low.

METHODS

Qualitative interview study. 30 interviews with 25 male and 5 female prisoners with a history of injecting drug use.

RESULTS

Personal and institutional barriers to uptake of testing for HCV were identified. Personal barriers included: prisoners' fears and lack of knowledge about HCV, low motivation for testing, lack of awareness about the testing procedure, and concerns about confidentiality and stigma. Institutional barriers included: the prisons' applications procedure for testing, inadequate pre- and post-test discussion, lack of pro-active approaches to offering testing, and lack of continuity of care on discharge and transfer.

CONCLUSION

This study highlights potential areas of development in the management of HCV in prisons. Further research is needed to evaluate care pathways for HCV in the prison setting and to develop and assess interventions to improve the uptake of testing for HCV by prisoners.

Exploring risk perception and behaviour of homeless injecting drug users diagnosed with hepatitis C

Injecting drug users (IDUs) are at the greatest risk of hepatitis C infection by using any item of injecting equipment that has come into contact with contaminated blood. Alongside this, homeless IDUs have been identified as being at increased risk of harm in their illicit drug taking behaviour. This study interviewed 17 hepatitis C positive homeless IDUs about their injecting practices. In-depth interviews explored the impact of a positive hepatitis C diagnosis on their injecting and identified their risk behaviours and perceptions. The interviews were tape-recorded, transcribed and analysed using the framework approach. Homeless IDUs engaged in both high risk and unhygienic injecting practices, such as using drugs outside and in public places, sharing injecting equipment and re-using cleaned needles. Excessive needle reuse whilst in prison was also identified. However, the findings were not universally bleak as a positive diagnosis of hepatitis C did lead to some behaviour change towards safer injecting and some adopted other lifestyle and behaviour changes. It was, however, common for homeless people to devolve responsibility for preventing hepatitis C transmission to their peers, especially when injecting with others. Knowledge regarding possible transmission through injecting paraphernalia appeared to make users more careful to reduce it through these routes. Placing a continuous emphasis on health promotion is therefore important in educating IDUs about the hepatitis C transmission risks associated with injecting drug use. Information regarding safer and hygienic use, including accurate information regarding the most effective methods to clean used equipment, must be re-enforced by people working with homeless injecting drug users.

Hepatitis C and its risk management among drug injectors in London: renewing harm reduction in the context of uncertainty

AIM

Recognizing the dearth of qualitative research on hepatitis C virus (HCV) infection associated with injecting drug use in the UK, this paper summarizes qualitative insights from a study exploring the social relations of HCV risk management among drug injectors in London.

METHOD

Adopting an inductive approach to data collection and analysis, 59 depth tape-recorded qualitative interviews were undertaken in 2001 with drug injectors recruited via drug user networks.

RESULTS

While access to injecting equipment was reportedly good, needle and syringe sharing continued in exceptional circumstances and in the context of 'trust relationships'. Analyses of drug injectors' accounts of variations of 'I never share' showed that this construction denoted less a descriptor of actual risk behaviour than presentation of perceived risk status. Paraphernalia sharing, including spoons and filters, was common. There was much confusion and uncertainty concerning HCV knowledge, including its medical and transmission risks. Injectors were aware of the provisionality and partiality of their HCV knowledge. Confusion also surrounded the meaning of HCV antibody test results, with some feeling that their positive diagnosis had been 'trivialized' by their experiences of HCV testing. Injectors tended to make sense of HCV risk in relation to HIV. With most viewing HCV prevalence as high and HCV transmission as an inevitable consequence of injecting, HCV risk was perceived as ubiquitous and unavoidable.

CONCLUSIONS

There is an urgent need to renew UK policies of harm reduction in order to support perceptions that HCV is avoidable and preventable.