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Morris MD, McDonell C, Luetkemeyer AF, Thawley R, McKinney J, Price JC. Community-Based Point-of-Diagnosis Hepatitis C Treatment for Marginalized Populations: A Nonrandomized Controlled Trial. JAMA Netw Open 2023; 6:e2338792. [PMID: 37862013 PMCID: PMC10589813 DOI: 10.1001/jamanetworkopen.2023.38792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/06/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Disparities persist in testing and treatment for hepatitis C virus (HCV), leaving socially marginalized populations less likely to benefit from curative treatment. Linkage services are often insufficient to overcome barriers to navigating the medical system and contextual factors. Objective To determine the feasibility, acceptability, and safety of HCV treatment at the point of HCV infection diagnosis disclosure in a nonclinical community setting. Design, Setting, and Participants In this single-arm nonrandomized controlled trial conducted between July 1, 2020, and October 31, 2021, street-outreach recruitment targeted people experiencing homelessness and injecting drugs in an urban US community who were eligible for simplified HCV treatment. Interventions Study procedures were designed to reflect the community environment and services needed to provide HCV testing, disclosure, and treatment in a nonclinical site. The test-and-treat No One Waits (NOW) model of care provided a 2-week starter pack of 400 mg of sofosbuvir and 100 mg of velpatasvir at time of HCV RNA results disclosure. Participants were transitioned to insurance-provided sofosbuvir-velpatasvir when feasible to complete a 12-week treatment course. Main Outcomes and Measures The primary end point was sustained virologic response at posttreatment week 12 or later (SVR12). Acceptability end points were treatment initiation and completion. Safety end points were treatment discontinuation because of a late exclusion criterion and adverse events. Results Of the 492 people (median [IQR] age, 48 [37-58] years; 62 [71%] male) who underwent anti-HCV testing, 246 (50%) tested anti-HCV positive, and 111 (23%) tested HCV RNA positive and were eligible for simplified HCV treatment. Eighty-nine of the 111 eligible participants (80%) returned for confirmatory RNA results, and 87 (98%) accepted and initiated HCV treatment. Seventy (80%) were currently injecting drugs, 83 (97%) had an income below the poverty line, and 53 (61%) were currently unsheltered. Most had HCV genotype 1a (45 [52%]) or 3 (20 [23%]). Sixty-nine (79%) completed 12 weeks of sofosbuvir-velpatasvir treatment, 2 stopped treatment because of low adherence, and 16 were lost to follow-up. Of the 66 participants who completed treatment and had a successful blood draw, 61 (92%) had undetectable HCV RNA at treatment completion. Of the 87 treated patients, 58 achieved SVR12, leading to a treatment response of 67% (95% CI, 56%-76%) among the intention-to-treat group and 84% (95% CI, 73%-92%) among the per-protocol group. There were no adverse events, late exclusions, or deaths. Conclusions and Relevance In this nonrandomized controlled trial of HCV treatment at the point of diagnosis, the NOW model of care reduced steps between HCV testing and treatment initiation and resulted in high levels of treatment initiation, completion, and cure. The NOW model of care can expand the current HCV test-and-treat toolkit by reaching a broader population of marginalized communities and expediting curative therapy. Trial Registration ClinicalTrials.gov Identifier: NCT03987503.
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Affiliation(s)
- Meghan D. Morris
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Claire McDonell
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Robert Thawley
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeff McKinney
- Liver Center, University of California, San Francisco
| | - Jennifer C. Price
- Department of Medicine, University of California, San Francisco
- Liver Center, University of California, San Francisco
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Bardach SH, Perry AN, Eccles E, Carpenter-Song EA, Fowler R, Miers EM, Ovalle A, de Gijsel D. Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report. J Particip Med 2023; 15:e47395. [PMID: 37728975 PMCID: PMC10551795 DOI: 10.2196/47395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/02/2023] [Accepted: 08/31/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs. OBJECTIVE This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges. METHODS Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges. RESULTS Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes. CONCLUSIONS While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.
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Affiliation(s)
- Shoshana H Bardach
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
| | - Elizabeth Eccles
- Section of Infectious Diseases & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | | | - Ryan Fowler
- HIV/HCV Resource Center, Lebanon, NH, United States
| | - Erin M Miers
- Park Nicollet Health Services, Minneapolis, MN, United States
| | | | - David de Gijsel
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
- Section of Infectious Diseases & International Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Better Life Partners, Manchester, NH, United States
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Gunn AJ, Hardesty M, Overstreet N, Wallace S. "Every time I tell my story I learn something new": Voice and inclusion in research with Black women with histories of substance use and incarceration. CRIMINOLOGY & CRIMINAL JUSTICE : THE INTERNATIONAL JOURNAL OF POLICY AND PRACTICE 2022; 22:505-524. [PMID: 38362478 PMCID: PMC10868846 DOI: 10.1177/17488958211005820] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
While current ethical procedures aim to minimize risks to imprisoned individuals, there is heightened awareness of the need to protect those who participate in research post-incarceration while under community-based supervision. Formerly incarcerated women, in particular, face myriad challenges to community reintegration which also make them vulnerable participants in research. As such, this study explores how 28 formerly incarcerated Black women experience the qualitative research process. Findings revealed that women engaged in research because these contexts were viewed as therapeutic spaces for raising awareness that can help others. Moreover, the interview process allowed women to share their pasts in ways that promote their recovery from addiction. Participants also reported risks of emotional distress and fears regarding researcher stigma. The implications for trauma-informed interviewing practices underscore the need for greater considerations of the role of the researcher, research environment, and how they contribute to one's personal recovery.
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Cioffi CC, Kosty D, Capron CG, Tavalire HF, Barnes RC, Mauricio AM. Contingency Management and SARS-CoV-2 Testing Among People Who Inject Drugs. Public Health Rep 2022; 137:573-579. [PMID: 35238240 PMCID: PMC9109524 DOI: 10.1177/00333549221074385] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES People who inject drugs (PWID) are especially vulnerable to morbidity and mortality as a result of SARS-CoV-2 infection because of social and physical health vulnerabilities. Routine testing for SARS-CoV-2 is critical to reduce transmission. Contingency management-the provision of tangible rewards to reinforce positive behavior-can promote the use of health services among PWID. Evidence is scarce on the utility of contingency management to promote SARS-CoV-2 testing. The objective of this study was to evaluate the effectiveness of contingency management to increase testing among PWID. METHODS SARS-CoV-2 testing was implemented at 9 syringe exchange program sites in partnership with an Oregon-based nonprofit organization for 5 weeks without contingency management and for 6 weeks with contingency management (a $10 financial incentive for testing) from February 1 through mid-April 2021. We measured rates of testing among syringe exchange program clients before and after implementation of contingency management. RESULTS Before contingency management, SARS-CoV-2 testing occurred during approximately 131 of 1410 (9.3%) client encounters, and 123 of 997 (12.3%) unique clients were tested. During contingency management, testing occurred during approximately 571 of 1756 (32.5%) client encounters, and 407 of 1151 (35.4%) unique clients were tested. Rates of testing increased from 0.04 (SD, 0.04) before contingency management implementation to 0.25 (SD, 0.15) after implementation (t8 = -3.88; P = .005; Cohen d = 1.46). CONCLUSIONS Contingency management facilitated uptake of SARS-CoV-2 testing among PWID. Contingency management may be an effective strategy for improving communicable disease testing beyond testing for SARS-CoV-2 and for improving vaccine uptake among PWID and warrants additional research.
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Affiliation(s)
- Camille C. Cioffi
- Prevention Science Institute,
University of Oregon, Eugene, OR, USA,Camille C. Cioffi, PhD, University of
Oregon, Prevention Science Institute, 1600 Millrace Dr, Eugene, OR 97401, USA.
| | - Derek Kosty
- Prevention Science Institute,
University of Oregon, Eugene, OR, USA
| | | | | | | | - Anne Marie Mauricio
- Prevention Science Institute,
University of Oregon, Eugene, OR, USA,College of Education, University of
Oregon, Eugene, OR, USA
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Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention. AIDS Behav 2021; 25:3987-3999. [PMID: 34138377 PMCID: PMC8210500 DOI: 10.1007/s10461-021-03353-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 01/05/2023]
Abstract
Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention’s women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women’s focus; and consider providing same-day PrEP.
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Jaffe K, Korthuis T, Richardson L. 'This could be my last chance': Therapeutic optimism in a randomised controlled trial for substance use disorders. SOCIOLOGY OF HEALTH & ILLNESS 2021; 43:1286-1300. [PMID: 34117637 DOI: 10.1111/1467-9566.13297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/21/2021] [Accepted: 04/26/2021] [Indexed: 06/12/2023]
Abstract
In randomised controlled trials (RCTs), 'therapeutic optimism' describes a participant's belief they will benefit from the study treatment, despite the express goal of RCTs to test unknown aspects of interventions. Harbouring such expectations may interfere with RCT participation experiences, particularly among marginalised populations, such as people with substance use disorders (PSUD) who may experience social and structural barriers to participation that also increase their vulnerability to therapeutic optimism. However, little research explores therapeutic optimism within substance use trials. Thus, we conducted a nested qualitative study within an RCT testing a treatment for alcohol and opioid use disorders in HIV clinics. Using interviews with 22 participants in Vancouver, Canada, analysis revealed themes relevant to therapeutic optimism, that were specifically linked to intrinsic (e.g. health-related) or extrinsic motivations (e.g. stipend). First, compared to extrinsically motivated participants, intrinsically motivated participants held high expectations for the trial and attributed greater agency to the study medication. Second, intrinsically motivated participants expressing therapeutic optimism anticipated marked changes in their lives from the study/medication. Finally, some participants predicted the treatment would solve substance-related issues in their communities. These findings highlight the interplay between therapeutic optimism and complex interpretations of RCT objectives among PSUD.
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Affiliation(s)
- Kaitlyn Jaffe
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Sociology, University of British Columbia, Vancouver, BC, Canada
| | - Todd Korthuis
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lindsey Richardson
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Sociology, University of British Columbia, Vancouver, BC, Canada
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Abadie R, Fisher C, Dombrowski K. "He's under oath": Privacy and Confidentiality Views Among People Who Inject Drugs Enrolled in a Study of Social Networks and Human Immunodeficiency Virus/Hepatitis C Virus Risk. J Empir Res Hum Res Ethics 2021; 16:304-311. [PMID: 33769904 DOI: 10.1177/15562646211004411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite the promise of social network research, this method raises important ethical questions regarding privacy and confidentiality. Although researchers and bioethicists have considered research obligations in relation to marginal or vulnerable populations, the views of people who inject drugs (PWIDs) have not been sufficiently considered. To elicit participants' views of research obligations, we conducted in-depth interviews with a subset (n = 40) of active PWIDs enrolled in a large social network study. Findings suggest participants have an expectation of confidentiality but believe this obligation need not be absolute and can be waived if a participant violates community norms or place others at risk. Ethics boards should recognize that marginalized populations are able to articulate complex moral views about privacy and confidentiality. Engaging participants in dialogue about the responsible conduct of research presents an opportunity to correct under- or overestimations of research vulnerabilities when such decisions are restricted to the perspectives of investigators or Institutional Review Board members.
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Affiliation(s)
- Roberto Abadie
- Department of Anthropology, 14719University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Celia Fisher
- Center Ethics Education, Fordham University, Bronx, NY, USA
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Mirzazadeh A, Hosseini-Hooshyar S, Shahesmaeili A, Bahramnejad A, Barshan A, Mousavian G, Najafi E, Sharifi H, Haghdoost AA, Briceno A, McFarland W, Page K. Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran. Subst Abuse Treat Prev Policy 2020; 15:56. [PMID: 32758246 PMCID: PMC7405425 DOI: 10.1186/s13011-020-00298-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/22/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators. METHODS Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach. RESULTS In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID. CONCLUSIONS Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.
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Affiliation(s)
- Ali Mirzazadeh
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Samira Hosseini-Hooshyar
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Armita Shahesmaeili
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | | | | | - Ghazal Mousavian
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Esmail Najafi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali-Akbar Haghdoost
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Alya Briceno
- University of California San Francisco, San Francisco, CA, USA
| | - Willi McFarland
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
- University of California San Francisco, San Francisco, CA, USA
| | - Kimberly Page
- Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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