Prevention and treatment of hepatitis C in injection drug users

Hepatitis Risk in Diabetes Compared to Non-Diabetes and Relevant Factors: A Cross-Sectional Study with National Health and Nutrition Examination Survey (NHANES), 2013-2018

This study aimed to identify the development of hepatitis B or C infection in diabetes patients compared to those without and to elucidate factors associated with the prevalence of hepatitis B or C infection in diabetes. We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2018. As evaluation factors, we included variables such as age, race, illicit drug use, and poverty. The diabetic group had a significantly higher prevalence of hepatitis B or C infection than the non-diabetic group (odds ratio (OR) = 1.73; 95% confidence interval (CI), 1.36-2.21, p < 0.01). In multivariate Cox regression, non-poverty and non-illicit drug use were lower risk factors contributing to hepatitis development in diabetes (hazard ratio (HR) = 0.50; 95% CI, 0.32-0.79, p < 0.01, and HR = 0.05; 95% CI, 0.03-0.08, p < 0.01, respectively). Logistic regression also showed that these factors were significant contributors to hepatitis development in the diabetic group (p < 0.01). In patients with diabetes, the development of hepatitis was higher than that in those without, and hepatitis development was influenced by poverty and illicit drug use. This may provide supporting evidence of response strategies for diabetes to care for hepatitis development in advance.

Community Perceptions of Harm Reduction and Its Implications for Syringe Exchange Policy

In the United States, the rising prevalence of opioid addiction has led to an increase in opioid-related overdose deaths and transmission of infectious disease. This resulted in the declaration of a national public health emergency and the need for harm reduction strategies such as syringe exchange. Florida has seen increases in blood-borne diseases and fatal/nonfatal opioid overdoses, yet harm reduction policy integration has been historically limited. To inform policy change, this study explores the perspectives of community members in Manatee County, Florida, on harm reduction services. Six focus groups were conducted with findings centralized around three emergent themes related to the implementation of a syringe exchange program: (a) awareness and acceptability; (b) facilitating factors; and (c) perceived barriers. The results of this qualitative research helped to inform the successful adoption of a local syringe exchange ordinance. Recommendations for community education and engagement regarding harm reduction policy are discussed.

Low rate of reinfection among a cohort of people who use drugs successfully treated for hepatitis C virus infection in Vancouver, Canada

INTRODUCTION

Concerns about reinfection may be limiting HCV treatment uptake among people who use drugs (PWUD), with rates of 17.1/100 person-years in some cohorts. The aim of this study was to evaluate reinfection following successful treatment for hepatitis C virus infection in a cohort of people who inject drugs in Vancouver, Canada.

METHODS

We identified a cohort of HCV-infected PWUD treated at our centre. Following cure, patients were maintained in long-term follow-up in a multidisciplinary program to address their medical, psychological, social, and addiction-related needs. HCV RNA measurements were repeated every 6 months, and ongoing drug use was documented. The primary outcome of this analysis was the occurrence of reinfection.

RESULTS

243 recent PWUD (use within 6 months of treatment initiation) have achieved SVR and maintained in long-term follow-up. Ongoing drug use post-treatment was documented in 195 individuals. Key characteristics: mean age 53 years, 25% female, 78% treatment naïve, 17% cirrhotic. Reinfection occurred in 4 cases, all in patients with ongoing drug use. This incidence was 1.05/100 [95% 0.8-5.2] person years based on 379 person-years of follow-up in individuals currently using drugs.

CONCLUSION

Approaches including long-term maintenance in multidisciplinary care may optimize long-term outcomes of HCV treatment in PWUD.

Evaluation of a hepatitis C education intervention with clients enrolled in methadone maintenance and needle/syringe programs in Malaysia

BACKGROUND

Approximately 40%-90% of people who inject drugs (PWID) in Malaysia have hepatitis C (HCV). PWID continue to be disproportionately affected by HCV due to their lack of knowledge, perceived risk and interest in HCV treatment. Education interventions may be an effective strategy for increasing HCV knowledge in PWID, and harm reduction services are uniquely positioned to implement and deploy such interventions.

METHODS

We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest.

RESULTS

Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session.

CONCLUSION

Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.

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.

Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations

Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.

Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

BACKGROUND

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7-28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally 'difficult to treat' genotypes (G1+G4) showed large variation (median 53, IQR 43-62). Twelve countries reported on HCV chronicity (median 72, IQR 64-81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2-28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38-64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5-15). Burden of disease, where assessed, was high and will rise in the next decade.

CONCLUSION

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

Confronting the emerging epidemic of HCV infection among young injection drug users

Hepatitis C virus infection is a significant public health problem in the United States and an important cause of morbidity and mortality. Recent reports document HCV infection increases among young injection drug users in several US regions, associated with America's prescription opioid abuse epidemic. Incident HCV infection increases among young injectors who have recently transitioned from oral opioid abuse present an important public health challenge requiring a comprehensive, community-based response. We summarize recommendations from a 2013 Office of HIV/AIDS and Infectious Disease Policy convening of experts in epidemiology, behavioral science, drug prevention and treatment, and other research; community service providers; and federal, state, and local government representatives. Their observations highlight gaps in our surveillance, program, and research portfolios and advocate a syndemic approach to this emerging public health problem.

Hepatitis-C multimedia prevention program in poor Hispanic HIV-infected injecting drug users: six months after intervention

BACKGROUND

In order to prevent the spread of the hepatitis C virus (HCV) amongst Hispanic injection drug users (IDUs), we developed, validated, and implemented a multimedia educational intervention program.

METHODS

A pre-post intervention study design was used to evaluate long-lasting knowledge and behavior changes in a group of 88 low-income Hispanic HIV-infected IDUs. Pre-intervention data was compared with data measured six months after the intervention.

RESULTS

A significant increase in the awareness regarding HCV clinical manifestations, HCV risky behaviors, HCV prevention practices, and HIV/HCV co-infection synergisms was observed in the group six months post-intervention.

CONCLUSION

Our study confirms the long-lasting benefits of multimedia based intervention programs for disseminating HCV prevention strategies in IDUs. Preventive educational approaches that use images, figures, and animations tools can be recommended to target and tailor interventions for vulnerable populations.

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.

Perceptions of drug users regarding hepatitis C screening and care: a qualitative study

BACKGROUND

Illicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.

METHODS

Fourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.

RESULTS

Many drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.

CONCLUSION

Drug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

Treatment of chronic hepatitis C infection among current and former injection drug users within a multidisciplinary treatment model at a community health centre

The aim of the present prospective observational study was to assess uptake and success of hepatitis C virus (HCV) treatment among a group of former and current injection drug users with chronic HCV infection at the Street Health Centre in Kingston, Ontario. The Street Health Centre offers hepatitis C education, assessment and treatment within a multidisciplinary, integrated and collaborative treatment model of care delivered by primary care professionals. The study enrolled a convenience sample of 34 patients. Seventy per cent of study patients had no postsecondary education, 85% were unemployed and one-third were unstably housed. A majority of study patients self-reported mental health problems. Of the 14 patients who initiated antiviral treatment in the study period, eight (57%) achieved sustained virological response. Regardless of virological outcome, patients who initiated treatment showed positive trends toward increased social and psychiatric stability, and decreases in high-risk behaviours. These results suggest that not only is successful treatment of chronic HCV infection in current and former injection drug users with concurrent psychiatric disorders possible, but the benefits of such treatment delivered in a community-based, multidisciplinary, primary care model may extend beyond narrowly defined virological outcomes.

Low rates of hepatitis C testing among people who inject drugs in Thailand: implications for peer-based interventions

BACKGROUND

Regular testing for hepatitis C virus (HCV) provides an opportunity for HCV prevention and treatment efforts. In Thailand, the barriers and facilitators of HCV testing among people who inject drugs (IDU) are not known.

METHODS

Using data derived from the Mitsampan Community Research Project between July and October 2011, we assessed the prevalence and factors associated with ever having been tested for HCV antibodies using bivariate statistics and multivariate logistic regression.

RESULTS

Among 427 participants, 141 (33.0%) reported a history of HCV antibody testing. In multivariate analyses, factors positively associated with receiving an HCV antibody test included higher than secondary education [adjusted odds ratio (AOR) = 2.20; 95% confidence interval (CI): 1.35-3.64], binge drug use (AOR = 1.81; 95% CI: 1.12-2.93), methadone treatment enrollment (AOR = 3.47; 95% CI: 1.85-6.95) and having received peer-based education on HCV (AOR = 4.22; 95% CI: 2.66-6.77).

CONCLUSIONS

We found one-third of Thai IDU in our sample reporting a history of HCV testing. The finding that IDU who received peer-based HCV education were more likely to access HCV testing provides evidence for the value of peer-based interventions for this population.

Predictors of active injection drug use in a cohort of patients infected with hepatitis C virus

OBJECTIVES

We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).

METHODS

We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.

RESULTS

Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.

CONCLUSIONS

Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.

Chronic hepatitis C and antiviral treatment regimens: where can psychology contribute?

OBJECTIVE

Our goal was to evaluate the existing literature on psychological, social, and behavioral aspects of chronic hepatitis C viral (HCV) infection and antiviral treatment; provide the state of the behavioral science in areas that presently hinder HCV-related health outcomes; and make recommendations for areas in which clinical psychology can make significant contributions.

METHOD

The extant literature on HCV and antiviral therapy was reviewed as related to biopsychosocial factors such as mental health, substance/alcohol use, quality of life, coping, stigma, racial disparities, side effects, treatment adherence, integrated care, and psychological interventions.

RESULTS

For reasons that have not been well elucidated, individuals infected with HCV experience psychological and somatic problems and report poor health-related quality of life. Preexisting conditions, including poor mental health and alcohol/substance use, can interfere with access to and successful completion of HCV treatment. Perceived stigma is highly prevalent and associated with psychological distress. Racial disparities exist for HCV prevalence, treatment uptake, and treatment success. During HCV treatment, patients experience exacerbation of symptoms, treatment side effects, and poorer quality of life, making it difficult to complete treatment. Despite pharmacological advances in HCV treatment, improvements in clinical and public health outcomes have not been realized. The reasons for this lack of impact are multifactorial, but include suboptimal referral and access to care for many patients, treatment-related side effects, treatment nonadherence, and lack of empirically based approaches.

CONCLUSIONS

Biomedical advances in HCV and antiviral treatment have created a fertile field in which psychologists are uniquely positioned to make important contributions to HCV management and treatment.

Patient Characteristics Associated with HCV Treatment Adherence, Treatment Completion, and Sustained Virologic Response in HIV Coinfected Patients

Background. Hepatitis C (HCV) treatment efficacy among HIV patients is limited by poor treatment adherence and tolerance, but few studies have examined the psychosocial determinants of treatment adherence and outcomes. Methods. Chart abstracted and survey data were collected on 72 HIV patients who had received pegylated interferon and ribavirin to assess correlates of treatment adherence, completion, and sustained virologic response (SVR). Results. Nearly half (46%) the sample had active psychiatric problems and 13% had illicit drug use at treatment onset; 28% reported <100% treatment adherence, 38% did not complete treatment (mostly due to virologic nonresponse), and intent to treat SVR rate was 49%. Having a psychiatric diagnosis was associated with nonadherence, while better HCV adherence was associated with both treatment completion and SVR. Conclusions. Good mental health may be an indicator of HCV treatment adherence readiness, which is in turn associated with treatment completion and response, but further research is needed with new HCV treatments emerging.

Barriers to receiving hepatitis C treatment for people who inject drugs: Myths and evidence

BACKGROUND

Alcohol consumption, current injecting drug use, and pre-existing mental illness have been identified as 3 of the main reasons for excluding patients from treatment for hepatitis C.

OBJECTIVES

We reviewed the literature to obtain an evidence base for these common exclusion criteria.

MATERIALS AND METHODS

We reviewed original research and meta-analyses investigating the effects of alcohol consumption, current injecting drug use, and pre-existing mental illness.

RESULTS

We identified 66 study reports relevant to the review, but found only limited evidence to support withholding of treatment on the basis of the 3 previously mentioned exclusion criteria.

CONCLUSIONS

Currently, there is a lack of evidence for many of the barriers faced by patients in availing treatment for hepatitis C. Adherence to treat routine was found to be a better predictor of sustained virological response than injecting drug or alcohol consumption during treatment period or the presence of a pre-existing mental disorder. Although several challenges remain, we need to ensure that treatment decisions are based on the best available evidence and the treatment is performed appropriately on a case-by-case basis.

Physicians' attitudes and practice toward treating injection drug users with hepatitis C: results from a national specialist survey in Canada

BACKGROUND

In Canada, more than 70% of new cases of hepatitis C virus (HCV) infection per year involve injection drug users (IDUs) and, currently, there is no consensus on how to offer them medical care.

OBJECTIVE

To examine the characteristics of Canadian specialist physicians and their likelihood to provide treatment to HCV patients who are IDUs.

METHODS

A nationwide, cross-sectional study was conducted in the specialty areas of hepatology, gastroenterology and infectious diseases to examine HCV services. The questionnaire requested information regarding basic demographics, referral pathways and opinions (yes⁄no), and examined how a physician's treatment regimen is influenced by factors such as treatment eligibility, HCV care management and barriers to providing quality service.

RESULTS

Despite the fact that the majority of prevalent and incident cases of HCV are associated with injection drug use, very few specialist physicians actually provide the necessary therapy to this population. Only 19 (19.79%) comprehensive service providers were likely to provide treatment to a current IDU who uses a needle exchange on a regular basis. The majority of comprehensive service providers (n=86 [89.58%]) were likely to provide treatment to a former IDU who was stable on substitution therapy. On bivariate analysis, factors associated with the likelihood to provide treatment to current IDUs included physicians' type, ie, infectious disease specialists compared with noninfectious specialists (OR 3.27 [95% CI 1.11 to 9.63]), and the size of the community where they practice (OR 4.16 [95% CI 1.36 to 12.71] [population 500,000 or greater versus less than 500,000]). Results of the multivariate logistic regression analysis were largely consistent with the results observed in the bivariate analyses. After controlling for other confounding variables, only community size was significantly associated with providing treatment to current IDUs (OR 3.89 [95% CI 1.06 to 14.26] [population 500,000 or greater versus less than 500,000]).

CONCLUSION

The present study highlighted the reluctance of specialists to provide treatment to current IDUs infected with HCV. Providing treatment services for HCV-infected substance abusers is challenging and there are many treatment barriers. However, effective delivery of treatment to this population will help to limit the spread of HCV. The present study clearly identified a need for improved HCV treatment accessibility for IDUs.

Treatment of acute HCV infection

In developed nations, the majority of new HCV infections are acquired by injection drug users. Acute HCV infection is generally asymptomatic and is followed by spontaneous viral clearance in approximately 25% of individuals. However, given the asymptomatic nature of infection and difficulties in identifying and following those at risk of acquiring infection, our knowledge of treatment for acute HCV infection has been hampered. Much of what is known about the timing, optimal regimen and duration of therapy comes from small, prospective, observational studies and randomized, controlled trials in selected populations. Furthermore, data on the treatment of acute HCV infection among injection drug users and patients co-infected with HCV and HIV are limited. Genetic testing for variations in IL28B may provide an additional diagnostic tool for the optimal management and treatment of acute HCV infection. This Review highlights current knowledge of the epidemiology, diagnosis, natural history and treatment of acute HCV infection, including proposed recommendations for the assessment and treatment of this infection.

Low rates of hepatitis A and B vaccination in patients with chronic hepatitis C at an urban methadone maintenance program

Patients with chronic hepatitis C virus (HCV) are at increased risk for complications of liver disease if they become infected with the hepatitis A (HAV) or hepatitis B (HBV) viruses. The authors examined the rates of testing for HAV, HBV, and HCV, as well as rates of vaccination against HAV and HBV in patients with chronic HCV in a random sample (N = 207) of medical records of patients enrolled in a methadone maintenance program. Almost all patients reviewed were tested for HAV, HBV, and HCV. Of the 111 patients with chronic HCV, 53 (48.6%) and 68 (63%) lacked immunity to HAV and HBV, respectively. Of those lacking immunity, 29 (54.7%) and 2 (2.9%) were vaccinated for HAV and HBV, respectively. Despite high rates of testing for HAV, HBV, and HCV at a methadone maintenance program, approximately half of those with chronic HCV eligible for the HAV vaccine received it, and few of those eligible for HBV vaccine received it.

Factors to improve the management of hepatitis C in drug users: an observational study in an addiction centre

Barriers to management of HCV in injection drug users are related to patients, health providers, and facilities. In a primary care drug user's addiction centre we studied access to HCV standard of care before and after using an onsite total care concept provided by a multidisciplinary team and noninvasive liver fibrosis evaluation. A total of 586 patients were seen between 2002 and 2004. The majority, 417 patients, were HCV positive and of these patients 337 were tested positive for HCV RNA. In 2002, patients were sent to the hospital. with the Starting of 2003, patients were offered standard of care HCV management in the center by a team of general practitioners, a consultant hepatologist, psychiatrists, nurses, and a health counsellor. Liver fibrosis was assessed by a non invasive method. In 2002, 6 patients had liver fibrosis assessment at hospital facilities, 4 patients were assessed with liver biopsy and 2 patients with Fibrotest-Actitest. 2 patients were treated for HCV at hospital. In 2003 and 2004, 224 patients were assessed with Fibrotest-Actitest on site. Of these, 85 were treated for HCV. SVR was achieved in 43%. We conclude that the combination of an onsite multidisciplinary team with the use of a noninvasive assessment method led to improved management of HCV infection in drug users' primary care facility.

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.

Evaluation of morphological changes of the liver caused by heroin abuse in forensic practice

Background/Aim. A study of morphological lesions in the liver of heroin addicts enables a precise overview of the type and degree of the liver damages caused by intravenous (iv) heroin abuse, additive effects of viral infections and alcohol consumption, as well as whether the expressiveness of these lesions depends on the duration of the time period of heroin application. The aim of the study was to investigate histopathological, ultrastructural and morphometric features of the liver of heroin addicts in forensic samples of the liver. Methods. The study involved the autopsy conducted on 40 bodies of iv heroin addicts and 10 control autopsies. The investigated group consisted of liver samples of 36 male subjects and 4 female subjects aged 35-40 years and the control group of 8 male and 2 female cadaveric bodies aged 15-35 years. The liver tissue samples were prepared for light microscopy. Sections of the tissue paraffin blocks 5 ? thick were stained using classical Hematoxylin and Eosin method (H&E), as well as PAS Van Gieson, Gomori, and Congo Red techniques. For investigation purposes of ultrastructural changes, liver tissue was fixed in glutaraldehyde and molded with epon. The analysis was performed using the method of transmission electron microscopy. Morphometric investigation of the liver sinusoidal macrophages was performed by using the M42 test system. Results. In the investigated group of iv heroin addicts, the liver autopsy samples showed degenerative vesicular and fat changes, chronic hepatitis, cirrhosis, sedimentation of pathologic protein amyloidosis, dysplastic changes, reduction in the amount of glycogen in hepatocytes, as well as the change in the number of Kupfer and endothelial cells. The established changes correlated with the duration of iv heroin abuse, whereas sinusoidal macrophages were activated in cases with active hepatitis, and no significant change in their number was found in hepatocytes with alcohol-related fatty changes. Conclusion. The study showed that the most present change in the hepatocytes of drug addicts was vesicular degeneration, and it is the only direct consequence of the effect of heroin. Other morphological changes were present due to viral infections and they correlated with the duration of narcotic abuse. The finding of dysplastic changes in this susceptible population of young people is particularly significant. The forensic significance of the established changes in the liver tissue is in the possibility of their practical application for determination of the immediate cause of death of iv heroin addicts, as well as the differential diagnosis of not only heroin, but also alcohol, sedative and other substances abuse, and all that on the basis of morphological damages of the liver.

A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease

This study examined the impact of prison-initiated methadone maintenance at 12 months postrelease. Males with pre-incarceration heroin dependence (N = 204) were randomly assigned to (a) Counseling Only: counseling in prison, with passive referral to treatment upon release; (b) Counseling + Transfer: counseling in prison with transfer to methadone maintenance treatment upon release; and (c) Counseling + Methadone: counseling and methadone maintenance in prison, continued in the community upon release. The mean number of days in community-based drug abuse treatment were, respectively, Counseling Only, 23.1; Counseling + Transfer, 91.3; and Counseling + Methadone, 166.0 (p < .01); all pairwise comparisons were statistically significant (all ps < .01). Counseling + Methadone participants were also significantly less likely than participants in each of the other two groups to be opioid-positive or cocaine-positive according to urine drug testing. These results support the effectiveness of prison-initiated methadone for males in the United States. Further study is required to confirm the findings for women.

Treat early or wait and monitor? A qualitative analysis of provider hepatitis C virus treatment decision-making in the context of HIV coinfection

Liver disease is a leading cause of death among patients with HIV coinfected with hepatitis C (HCV); yet, studies show that less than 10% receive HCV treatment, in part because of limited treatment response, high treatment toxicity, and psychosocial barriers to treatment readiness. Using a process model framework, we sought to explore the factors and processes by which providers make HCV treatment decisions for HIV-coinfected patients. We conducted 22 semistructured interviews with primary care providers and support staff at three HIV clinics in Los Angeles, California, in which rates of HCV treatment uptake varied from 10% to 38%. Providers agreed that stable HIV disease, favorable genotype, and significant signs of liver disease progression are all signs of need for treatment. However, two divergent treatment approaches emerged for genotype 1 and 4 patients with minimal disease, and in definitions of patient readiness. Providers with lower treatment rates preferred to delay treatment in hopes of better future treatment options, and were more conservative in requiring complete mental health screens and treatment and abstinence from substance use. Conversely, providers with higher treatment rates viewed all patients as needing treatment as soon as possible, and defined readiness more leniently, with some willing to treat even in the context of untreated depression and drug use, so long as ability to adhere well was demonstrated. Regardless of whether an aggressive or cautious approach to treatment is used, development of effective programs for promoting patient treatment readiness is critical to ensuring greater treatment uptake.

The HCV Synthesis Project: scope, methodology, and preliminary results

Background

The hepatitis C virus (HCV) is hyper-endemic in injecting drug users. There is also excess HCV among non-injection drug users who smoke, snort, or sniff heroin, cocaine, crack, or methamphetamine.

Methods

To summarize the research literature on HCV in drug users and identify gaps in knowledge, we conducted a synthesis of the relevant research carried out between 1989 and 2006. Using rigorous search methods, we identified and extracted data from published and unpublished reports of HCV among drug users. We designed a quality assurance system to ensure accuracy and consistency in all phases of the project. We also created a set of items to assess study design quality in each of the reports we included.

Results

We identified 629 reports containing HCV prevalence rates, incidence rates and/or genotype distribution among injecting or non-injecting drug user populations published between January 1989 and December 2006. The majority of reports were from Western Europe (41%), North America (26%), Asia (11%) and Australia/New Zealand (10%). We also identified reports from Eastern Europe, South America, the Middle East, and the Caribbean. The number of publications reporting HCV rates in drug users increased dramatically between 1989 and 2006 to 27–52 reports per year after 1998.

Conclusion

The data collection and quality assurance phases of the HCV Synthesis Project have been completed. Recommendations for future research on HCV in drug users have come out of our data collection phase. Future research reports can enhance their contributions to our understanding of HCV etiology by clearly defining their drug user participants with respect to type of drug and route of administration. Further, the use of standard reporting methods for risk factors would enable data to be combined across a larger set of studies; this is especially important for HCV seroconversion studies which suffer from small sample sizes and low power to examine risk factors.

A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release

AIMS

This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release.

DESIGN

A three-group randomized controlled trial was conducted between September 2003 and June 2005.

SETTING

A Baltimore pre-release prison.

PARTICIPANTS

Two hundred and eleven adult pre-release inmates who were heroin-dependent during the year prior to incarceration.

INTERVENTION

Participants were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71).

MEASUREMENTS

Addiction Severity Index at study entry and follow-up. Additional assessments at 6 months post-release were treatment record review; urine drug testing for opioids, cocaine and other illicit drugs.

FINDINGS

Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants.

CONCLUSIONS

Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients

AIMS

Hepatitis C virus (HCV) infection is a common chronic complication of injection drug use. Methadone maintenance programs contain large numbers of patients infected with HCV. This paper reviews HCV infection with emphasis on the medical care of HCV-infected, or HCV and human immunodeficiency virus co-infected, patients on methadone or buprenorphine maintenance.

METHODS

Literature searches using PubMed, PsycINFO and SocINDEX were used to identify papers from 1990-present on antiviral therapy for HCV in methadone maintenance patients and on liver transplantation in methadone maintenance patients.

RESULTS

Injection drug use is the most significant risk factor for HCV infection in most western countries. The prevalence of HCV antibody is high in injection drug users (53-96%) and in patients enrolled in methadone maintenance programs (67-96%). Studies of antiviral therapy for HCV in methadone maintenance patients show rates of sustained virological response (SVR), defined as negative HCV-RNA 24 weeks after the end of treatment, of 28-94%. In studies with contrast groups, no significant differences in SVR between methadone and contrast groups were found. Excellent completion rates of antiviral therapy (72-100%) were found in five of six studies. There are many barriers to methadone maintenance patients' receiving antiviral therapy, and research on overcoming barriers is discussed. Liver transplantation has been successful in methadone maintenance patients but has not been utilized widely.

CONCLUSION

High quality medical care for all aspects of HCV infection can be provided to methadone maintenance patients. The literature supports the effectiveness of such services, but the reality is that most patients do not receive them.

Hepatitis C for addiction professionals

A disease whose reputation is often worse than its reality, hepatitis C is usually benign. Most infected individuals do not experience symptoms requiring treatment, and roughly half of those treated will become free of detectable virus for an extended, perhaps permanent, period. Moreover, a growing body of data suggests that drug users can attain successful treatment outcomes, even when not completely abstinent. Addiction professionals belong in the forefront of prevention and management of this disease. We can assist our patients by helping them stabilize their lifestyles, correcting misperceptions about the disease, teaching prevention and health maintenance, promoting access to diagnosis and treatment, monitoring for treatment side effects, and providing encouragement to remain in treatment.

Exploring drug users' attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S

Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programmes (MMTPs) reporting that 60-90 percent of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42-82 percent of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programmes throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider, initiate HCV treatment or both. Gaining a better understanding of drug users' perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future.

A Study of Methadone Maintenance For Male Prisoners: 3-Month Postrelease Outcomes

This study examined benefits of methadone maintenance among prerelease prison inmates. Incarcerated males with preincarceration heroin dependence (n = 197) were randomly assigned to (a) group educational counseling (counseling only); (b) counseling, with opportunity to begin methadone maintenance on release (counseling + transfer); or (c) counseling and methadone maintenance in prison, with opportunity to continue methadone maintenance on release (counseling + methadone). At 90-day follow-up, counseling + methadone participants were significantly more likely than counseling-only and counseling + transfer participants to attend drug treatment (p = .0001) and less likely to be reincarcerated (p = .019). Counseling + methadone and counseling + transfer participants were significantly less likely (all ps < .05) to report heroin use, cocaine use, and criminal involvement than counseling-only participants. Follow-up is needed to determine whether these findings hold over a longer period.

A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release

BACKGROUND

Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction.

METHODS

A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n=70); counseling+transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n=70); and counseling+methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n=71).

RESULTS

Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling+methadone 68.6%, p<.05. All pairwise comparisons were statistically significant (all ps<.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling+transfer 41.0%, and counseling+methadone 27.6%, p<.05, with the counseling only group significantly more likely to test positive than the counseling+methadone group.

CONCLUSIONS

Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

Determinants of antiviral treatment initiation in a hepatitis C-infected population benefiting from universal health care coverage

BACKGROUND AND AIMS

In view of increasing therapeutic efficacy, the delivery of hepatitis C virus (HCV) antiviral treatment is expected to increase. Yet practical experience reveals a low rate of treatment, particularly among intravenous drug users. The aim of the present study was to examine the prevalence of HCV treatment and identify factors associated with HCV treatment in a population of patients evaluated in an academic hepatology outpatient clinic between 2001 and 2002.

PATIENTS AND METHODS

The charts of HCV-infected patients who attended the outpatient clinic of the liver division between January 2001 and December 2002 were retrospectively reviewed. Regression analyses were conducted to compare patients according to HCV treatment initiation.

RESULTS

Of 378 eligible patients (past intravenous drug users 61%), 143 (38%) initiated antiviral treatment. Enrolment in a methadone maintenance program and a strong willingness to get treatment were independently associated with treatment initiation, while current intravenous drug use, alcoholic liver damage on biopsy, precarious housing arrangements and personality disorders were negatively associated with treatment initiation. Among patients who were offered treatment, 40% refused (they did not differ from the treated group for past or current substance abuse).

CONCLUSIONS

Only 38% of eligible patients initiated treatment; treatment refusal was very common. The results of the present study showed that a significant barrier to therapy involved patient perceptions.

Seroprevalence of hepatitis C virus and hepatitis B virus among San Francisco injection drug users, 1998 to 2000

Previous studies suggest that most injection drug users (IDUs) become infected with hepatitis C virus (HCV) and hepatitis B virus (HBV) soon after initiating drug use. The Urban Health Study (UHS) recruited serial cross-sections of IDUs in the San Francisco Bay area from 1986 to 2005. In the current study, we determined the prevalence of antibody to HCV and HBV (core) among UHS participants during 1998 to 2000. To examine whether the time from onset of injection to acquisition of viral hepatitis has increased, we also compared the findings among recent (<10 years) initiates to drug use who participated during 1998-2000 with those who participated in 1987. Of 2,296 IDUs who participated during 1998-2000, 91.1% had antibody to HCV and 80.5% to HBV. The number of years a person had injected drugs strongly predicted infection with either virus (P(trend) < 0.0001). HCV seroprevalence among recent initiates in 1998-2000, by years of injection drug use, was: <or=2, 46.8%; 3 to 5, 72.4%; 6 to 9, 71.3%. By comparison, HCV seroprevalence among 1987 participants was: <or=2 years, 75.9%; 3 to 5, 85.7%; 6 to 9, 91.1% (P < 0.0001). A consistent pattern was observed for HBV (P < 0.0001), and these findings were not explained by demographic differences between 1987 and 1998-2000 participants. During 1987, however, 58.7% of recent initiates had shared syringes within the past 30 days compared with 33.6% during 1998-2000 (P < 0.0001).

CONCLUSION

HCV and HBV seroprevalence among newer initiates to injection drug use in the San Francisco Bay area decreased markedly between 1987 and 1998-2000. This decrease coincided with the implementation of prevention activities among this population.

Treatment of hepatitis C virus infection

Acute and chronic hepatitis C virus (HCV) infection remains a serious health problem worldwide, however, there has been advancement in the treatment of HCV infection due to standard treatment using pegylated interferon and ribavirin. The literature indicates that therapy for HCV is becoming more individualized. In addition to considering genotype and viral RNA levels before treatment, achievement of an early virologic response (EVR) and a rapid virologic response (RVR) is now possible during therapy. Moreover, problem patients, such as non-responders, relapsers, HIV or HBV co-infected patients, patients with liver cirrhosis, and pre- or post-liver transplantation patients are an increasing fraction of the patients requiring treatment. This article reviews the literature regarding standard treatments and problem patients with acute and chronic HCV infection. It also includes discussion on contraindications and side effects of treatment with interferon and ribavirin, as well as new drug development.

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.

Observed patterns of illicit opiate overdose deaths in Chicago, 1999-2003

This article explores trends and correlates of Chicago's opiate-related overdose (OD) deaths. We manually examined data from every death certificate filed between 1999 and 2003 to identify all Chicago residents' accidental deaths involving acute intoxication with illicit opiates, OD, or opiate poisoning. The analysis includes an examination of contextual characteristics in 77 Chicago neighborhoods. Negative binomial regression analysis permits the calculation of incidence rate ratios (IRR) associated with time trends. OD incidence peaked in 2000 and then declined markedly by 2003 [year 2000-2003 IRR = 0.65, 95% confidence interval (CI) (0.54, 0.78)]. Over the 2000-2003 period, overall incidence of fatal OD declined by 34%. Over this period, the sharpest observed declines occurred among African-Americans [IRR = 0.64, 95% CI (0.51, 0.81)] and Hispanics/Latinos [IRR = 0.53, 95% CI (0.32, 0.88)]. The opiate-related fatality incidence also declined among non-Hispanic whites [IRR = 0.743, 95% CI (0.52, 1.06)]. Even at the end of the study period, illicit opiate-related OD accounted for 35% of all accidental deaths to Chicago adults aged 18-64, with 45% of OD deaths occurring among African-American men. In summary, illicit opiate OD in Chicago peaked in 2000 and markedly declined by 2003. Opiate OD continues to pose a major threat of mortality to Chicago adults.

Therapeutic challenges in hepatitis C-infected injection drug using patients

Hepatitis C Viral (HCV) infection in the injection drug user (IDU) population is a major medical concern. Concurrent substance abuse, co-morbid mental health conditions, poor socioeconomic status and a complex treatment protocol that is often incompatible with the life styles of IDUs combine to account for poor uptake and completion of HCV treatment. This article discusses HCV antiviral treatment issues relevant to IDUs chronically infected with this virus. The effect of non-injected substances of abuse on treatment outcome is considered. Priority issues requiring research are discussed.

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.

Barriers to treatment of hepatitis C in HIV/HCV-coinfected adults with alcohol problems

BACKGROUND

Alcohol use and human immune deficiency virus (HIV) infection are both associated with accelerated progression of hepatitis C virus (HCV) disease and reduced response rates to interferon therapy. In this study, we assessed the prevalence of barriers to interferon treatment in a population of HIV/HCV-coinfected patients with current or past alcohol problems and the extent to which they received treatment to address the barriers.

METHODS

This is a cross-sectional, descriptive analysis of baseline data from a prospective study assessing the impact of HCV and alcohol use on HIV disease progression. Using consensus guidelines, subjects were categorized as having absolute, relative, or no contraindications to interferon therapy for HCV. Absolute contraindications to treatment included heavy alcohol use, decompensated liver disease, CD4 cell count <100 cells/microL, recent needle sharing, and suicidal ideation. Relative contraindications included moderate alcohol use, recent injection drug use, depressive symptoms, and CD4 cell count from 100 to 199 cells/microL.

RESULTS

Of 401 HIV-infected subjects, 200 were HCV RNA-positive. Fifty-three percent had an absolute contraindication to interferon therapy, 35% a relative but no absolute contraindication, and only 12% had no contraindication. Of those with an absolute contraindication, 61% reported heavy drinking and the majority (88%) had multiple contraindications. These contraindications were present despite the fact that over 50% were in receipt of substance abuse and mental health treatment.

CONCLUSIONS

Continued alcohol and drug use as well as depressive symptoms are the major barriers to interferon therapy in HCV/HIV-coinfected subjects and these barriers persist despite high treatment rates for these problems. Therefore, more intensive treatments of alcohol, drug, and mental health issues are needed to improve HCV treatment eligibility in HCV/HIV-coinfected persons.

Reinterpreting ethnic patterns among white and African American men who inject heroin: a social science of medicine approach

BACKGROUND

Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.

METHODS AND FINDINGS

We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its "War on Drugs." African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off "dopesickness" rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.

CONCLUSIONS

Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.

High prevalence of alcohol use among hepatitis C virus antibody positive injection drug users in three US cities

Injection drug users (IDUs) acquire the majority of new hepatitis C virus (HCV) infections and frequently use alcohol. Alcohol abuse accelerates liver disease among HCV-infected persons, can reduce the effectiveness of treatment for HCV infection and may be a contraindication for HCV treatment. HCV seropositive, HIV-negative IDUs aged 18-35 years in Baltimore, New York City and Seattle who were enrolled in a behavioral risk-reduction intervention trial underwent computerized self-interviews to assess baseline alcohol use and dependence and medical history. We measured problem alcohol use using the 10-item Alcohol Use Disorders Identification Test (AUDIT) scale. Of 598 participants, 84% responded "false" to: "it is safe for a person with HCV to drink alcohol". Problem drinking, defined as score > or =8 on AUDIT, was identified in 37%. Correlates of scoring > or =8 on AUDIT included homelessness, male gender, primarily injecting speedballs, having injected with used needles, prior alcohol treatment and depression. Although most HCV seropositive IDUs in our sample appear informed about their increased risk of liver disease from alcohol, two-fifths screened positive for problem alcohol use. These findings underscore the importance of referring HCV-positive persons to effective alcohol treatment programs to reduce future liver damage and improve eligibility for and effectiveness of treatment of HCV.

Risk factors for the transmission of hepatitis C virus infection in the Turkish population

The risk factors for the transmission of hepatitis C virus (HCV) infection varies substantially between countries and geographic regions. The aim of this investigation was to determine the risk factors which may be involved in the transmission of HCV infection in the Turkish population. This study included patients who were admitted to the Department of Gastroenterohepatology, Istanbul Medical Faculty, Istanbul University, between 1996 and 2002 and found to be anti-HCV positive during hospitalization or during follow-up as outpatients. All patients were asked about risk factors for HCV transmission including transfusion, history of operation, hospitalization, hemodialysis, intravenous drug use, suspected sexual contact, tattooing, acupuncture, dental procedures, manicure and pedicure, blood brotherhood rituals, perinatal risk factors, common circumcision rituals, and history of abortion. In our study, total of 320 patients with anti-HCV seropositivity were involved. The numbers and percentages of male and female patients were 139 (43.4%) and 181 (56.6%), respectively. The mean age of the patients was 49.7+/- 12.4 years (range: 18-73 years). HCV-RNA was found to be positive in 297 (92.8%) patients. The most common risk factor was a history of surgery (305; 98%), and the second most common was blood transfusion (123; 39.7%). The numbers and percentages of patients for the other risk factors were as follows: dental procedure, 86 (27.5%); abortion, 66 (21.2%); long-term hospitalization, 37 (11.6%); hemodialysis, 31 (10%); history of jaundice, 15 (4.6%); history of intravenous drug abuse, 10 (3.1%); history of suspected sexual contact, 5 (1.5%); history of manicure and pedicure, 4 (1.2%); history of occupational transmission, 3 (0.9%); history of tattooing, 2 (0.6%); history of acupuncture, 2 (0.6%); circumcision in a common circumcision ritual, 1 (0.3%); and percutaneous needle puncture, 1 (0.3%). None of the patients had a history of blood brotherhood ritual or perinatal transmission. Only one risk factor was detected in 73 (22.8%) patients, two risk factors were detected in 122 (38.2%) patients, three risk factors were detected in 78 (24.5%) patients, and four risk factors were detected in 39 (12.2%) patients, however, in 8 (1.6%) patients no risk factors could be found. In Turkey, the most common risk factor for the transmission of HCV infection is surgery, which can be preventable.

Factors associated with interest in initiating treatment for hepatitis C Virus (HCV) infection among young HCV-infected injection drug users

OBJECTIVE

We sought to identify factors associated with interest in receiving therapy for hepatitis C virus (HCV) infection among HCV-infected injection drug users (IDUs) in 3 United States cities.

METHODS

IDUs aged 18-35 years who were HCV-infected and seronegative for human immunodeficiency virus underwent surveys on behaviors, experience, and interest in treatment for HCV infection and readiness to quit drug use.

RESULTS

Among treatment-naive IDUs (n=216), 81.5% were interested in treatment for HCV infection, but only 27.3% had seen a health-care provider since receiving a diagnosis of HCV infection. Interest in treatment for HCV infection was greater among IDUs with a high perceived threat of progressive liver disease, those with a usual source of care, those without evidence of alcohol dependence, and those with higher readiness scores for quitting drug use. Interest in treatment for HCV infection was 7-fold higher among IDUs who were told by their health-care provider that they were at risk for cirrhosis or liver cancer.

CONCLUSIONS

Improving provider-patient communication and integrating treatments for substance abuse and HCV may increase the proportion of IDUs who initiate treatment for HCV infection.

Transforming growth factor-β1 gene polymorphisms are associated with progression of liver fibrosis in Caucasians with chronic hepatitis C infection

AIM: Considerable attention is focused on polymorphisms in the gene encoding transforming growth factor-β1 (TGF-β1), a multifunctional cytokine that is in turn a potent growth inhibitor involved in wound healing and differentiation. In humans, it promotes the pathogenesis of organ fibrosis, atherosclerosis, cancer, autoimmune and inflammatory diseases, keloid disease, and hypertrophic scarring. For this reason, much emphasis has been placed on studies elucidating the impact of TGF-β1 and its gene variations for the susceptibility and pathogenesis of these diseases. Unfortunately, some studies have serious limitations.

METHODS: We have recently described a high-throughput method for investigation the Arg25Pro polymorphism of human TGF-β1 gene and showed that the frequency of the Pro25 allele is significantly associated with hepatic fibrogenesis. In this report, we describe two novel LightCycler (LC) techniques that facilitate the examination of the two other known alterations in the coding region of TGF-β1. We investigated whether these polymorphisms contribute to hepatitis-induced progression of fibrogenesis in Chinese and Caucasians.

RESULTS: In the Chinese ancestry, the gene polymorphisms at codons 25 and 263 were not found and the genetic variant at codon 10 is unlikely to confer susceptibility to hepatic fibrosis. Contrarily, in Caucasians TGF-β1 allelic variations are more frequent and the presence of prolines either in codon 25 or 10 is associated with the interindividual variability in developing more severe fibrosis during chronic hepatitis C infection.

CONCLUSION: In summary, these results confirm the hypothesis that TGF-β1 polymorphisms are associated with fibrosis progression in Caucasians chronically infected with hepatitis C.

Infrequent reinfection after successful treatment for hepatitis C virus infection in injection drug users

We followed-up 18 injection drug users for a mean of 33.8 months (range, 4-55 months) after successful treatment for hepatitis C virus (HCV) infection. Fifteen (83%) of the patients remained HCV RNA-negative, 1 patient was not tested, and 2 patients had test results positive for HCV RNA. The estimated rate of reinfection as a result of injection drug use was 0-4.1 cases per 100 person-years (cumulative incidence, 0%-12.6% at 48 months after completion of treatment). Of 50 patients originally treated, 15 (30%) were HCV RNA-negative 3 years later.