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

The trouble with normalisation: Transformations to hepatitis C health care and stigma in an era of viral elimination

Modern health-care systems have customarily approached hepatitis C in ways that resemble the public health approach to HIV/AIDS known as 'HIV exceptionalism'. HIV exceptionalism describes the unusual emphasis on privacy, confidentiality and consent in approaches to HIV and was partly developed to address HIV/AIDS-related stigma. In the case of hepatitis C, exceptionalist approaches have included diagnosis and treatment by specialist physicians and other 'boutique' public health strategies. The recent availability of highly effective, direct-acting antivirals alongside goals to eliminate hepatitis C have heralded dramatic changes to hepatitis C health care, including calls for its 'normalisation'. The corollary to exceptionalism, normalisation aims to bring hepatitis C into routine, mainstream health care. This article draws on interviews with stakeholders (n = 30) who work with hepatitis C-affected communities in policy, community, legal and advocacy settings in Australia, alongside Fraser et al.'s (2017, International Journal of Drug Policy, 44, 192-201) theorisation of stigma, and Rosenbrock et al.'s (1999, The AIDS policy cycle in Western Europe: from exceptionalism to normalisation. WZB Discussion Paper, No. P 99-202) critique of normalisation to consider the perceived effects of hepatitis C normalisation. Stakeholders described normalisation as a stigma-reducing process. However, they also expressed concerns about the ongoing stigma and discrimination that is not ameliorated by normalisation. We suggest that in centring normalisation, changes in health care may exaggerate the power of technological solutions to transform the meanings of hepatitis C.

Reducing stigma towards people living with HIV and people who inject drugs using social norms theory: An online study with Australian health care workers

BACKGROUND

Despite extensive evidence regarding the negative effects of stigma experienced by people living with HIV (PLHIV) and people who inject drugs within health care settings, comparatively little evidence exists regarding the effectiveness of initiatives to reduce this stigma.

METHOD

This study developed and assessed brief online interventions based on social norms theory with a sample of Australian health care workers (n=653). Participants were randomly allocated to either 1) HIV intervention group, or 2) injecting drug use intervention group. They completed baseline measures of their attitudes towards either PLHIV or people who inject drugs, matching measures of their perceptions of their colleagues' attitudes, plus a series of items reflecting behavioural intentions and agreement with stigmatising behaviour towards PLHIV or people who inject drugs. Participants were presented with a social norms video before completing the measures again.

RESULTS

At baseline, participants' agreement with stigmatising behaviour was correlated with their perceptions of how many of their colleagues would agree. After watching the video, participants reported more positive perceptions of their colleagues' attitudes towards PLHIV and people who inject drugs, as well as more positive personal attitudes towards people who inject drugs. Changes in perceptions of colleagues' support for stigmatising behaviour independently predicted changes in participants' personal agreement with that behaviour.

CONCLUSION

Findings suggest that interventions based on social norms theory that address health care workers' perceptions of their colleagues' attitudes can play an important role in contributing to broader initiatives to reduce stigma in health care settings.

Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review

BACKGROUND AND AIM

People who inject drugs are at high risk of contracting hepatitis C (HCV). The introduction of direct acting antiviral (DAA) drugs to treat HCV has the potential to transform care; however, uptake of DAAs has been slower than anticipated. The strong link between HCV and injecting drug use frames HCV as a shameful, stigmatising disease, reinforcing an 'addict' identity. Linking HCV care to a recovery journey, 'clean' identity and social redemption may provide compelling encouragement for people to engage with treatment and re-evaluate risk and behaviours, reducing the incidence of HCV re-infection. The aim of this review was to identify actions, interventions and treatments that provide an opportunity for a change in identity and support a recovery journey and the implications for HCV care.

METHODS

Databases (MEDLINE, EMBASE, PsycINFO, ProQuest Public Health, ProQuest Sociological Abstracts, CINAHL and Web of Science) were searched following our published strategy and a grey literature search conducted. A narrative synthesis was undertaken to collate themes and identify common threads and provide an explanation of the findings.

RESULTS

Thirty-two studies fulfilled the inclusion criteria. The narrative synthesis of the studies identified five over-arching analytical themes: social factors in substance use and recovery, therapeutic communities, community treatment, online communities, and finally women and youth subsets. The change from an 'addict' identity to a 'recovery' identity is described as a key aspect of a recovery journey, and this process can be supported through social support and turning point opportunities.

CONCLUSIONS

Recovery from addiction is a socially mediated process. Actions, interventions and treatments that support a recovery journey provide social connections, a recovery identity and citizenship (reclaiming a place in society). There is a gap in current literature describing how pathways of care with direct acting antivirals can be designed to promote recovery, as part of hepatitis C care.

Barriers and Facilitators to Hepatitis C Virus (HCV) Treatment for Aboriginal and Torres Strait Islander Peoples in Rural South Australia: A Service Providers' Perspective

This study explored the barriers and facilitators to hepatitis C virus (HCV) treatment for Aboriginal and Torres Strait Islander peoples in rural South Australia as viewed from a healthcare provider perspective in the era of direct acting antivirals (DAAs). Phase 1 was a qualitative systematic review examining the barriers and enablers to diagnosis and treatment amongst Indigenous peoples living with HCV worldwide. Phase 2 was a qualitative descriptive study with healthcare workers from six de-identified rural and regional Aboriginal Community-Controlled Health Services in South Australia. The results from both methods were integrated at the analysis phase to understand how HCV treatment could be improved for rural Aboriginal and Torres Strait Islander peoples. Five main themes emerged: the importance of HCV education, recognizing competing social and cultural demands, the impact of holistic care delivery and client experience, the effect of internal barriers, and overlapping stigma, discrimination, and shame determine how Indigenous peoples navigate the healthcare system and their decision to engage in HCV care. Continued efforts to facilitate the uptake of DAA medications by Aboriginal and Torres Strait peoples in rural areas should utilize a multifaceted approach incorporating education to community and cultural awareness to reduce stigma and discrimination.

"Like a pickle that's been unpickled": Emotional, identity and behavioural transformations throughout hepatitis C treatment

BACKGROUND

Little is known about the emotional experience and benefits of undertaking direct acting antiviral (DAA) treatment for hepatitis C. A better understanding of individual treatment outcomes can inform acceptable treatment delivery and promotion. We aimed to explore participant-perceived emotional benefits and transformations throughout DAA treatment among people who inject drugs, who were initiating treatment.

METHODS

Participants were recruited from either a community based clinical trial or community health clinics. Semi structured interviews were conducted with each participant before, during and following treatment. Interviews focussed on treatment perceptions, physical and mental wellbeing and modifiable health behaviours. Interviews were recorded, transcribed verbatim and thematically analysed. Participant and cohort matrices were produced to assess at which time point themes were present and whether themes changed or remained stable over time.

RESULTS

This paper presents analysis from 19 participants interviewed between 2017-2019. Most participants were male, with no or mild fibrosis. At baseline, all but one participant had injected drugs in the past month. Three themes relating to the emotional wellbeing and behaviour change described a common treatment experience; 'hopes for better wellbeing', 'lifting the weight' and 'closing the chapter'. Participants were hopeful treatment would improve their emotional wellbeing. Hopes were actualised during treatment as participants began to feel uncertainty and stress easing. Completing treatment improved some participants perceptions of self. Some participants consciously changed their injecting behaviours during treatment.

CONCLUSION

Undertaking and completing treatment was an emotionally and behaviourally transformative period. Participant perceived benefits should be used to inform how treatment benefit is conceptualised and how treatment is promoted in primary care settings.

Experiences of Hope after Treatment of Hepatitis C Infection-A Qualitative Study

The aim of this study was to explore the experiences of hope people had after undergoing treatment for a hepatitis C virus infection (HCV). Between October 2019 and May 2020, 19 one-on-one interviews were conducted with people who inject drugs and had undergone HCV treatment. All participants had completed treatment and were documented as being virus-free. Data were audio recorded and then transcribed verbatim and analysed; a method inspired by reflexive thematic analysis. Those interviewed conveyed rich and nuanced descriptions of experiences of a life with HCV. Through the course of the analysis we developed four themes. The themes were formulated as metaphors aimed at capturing commonalities about how the participants seemed to "turn their gaze" after receiving HCV treatment: (1) turning their gaze backward; (2) turning their gaze inwards; (3) turning their gaze toward others and (4) turning their gaze forward. Participants' descriptions of their experiences relating to HCV were somewhat gloomy, and HCV treatment seemed to inspire hope and a brighter outlook on several areas of life.

What is known about the care and support provided for an ageing population with lived experience of chronic viral hepatitis as they near end-of-life: A scoping review

Ageing with a chronic hepatitis B (HBV) or hepatitis C (HCV) infection is an emerging public health priority. For people living with chronic viral hepatitis, their disease progression into old age is both underpinned by their existing blood borne virus and the potential emergence of other infectious and non-infectious conditions. These twinned pathways bring additional challenges to the care and support for people as they near end of life. This scoping review sought to examine what is known about the experiences of the end-of-life phase of an increasing population ageing with HBV and HCV in studies conducted in high-income settings and published in peer reviewed literature (2010-2021). In interpreting this literature, we found that challenges in determining the end-of life phase for people with lived experience of HBV or HCV are exacerbated by the conflation of aetiologies into a singular diagnosis of end-stage liver disease. Studies overwhelmingly reported the clinical aspects of end-of-life care (i.e. prognosis assessment and symptom management) with less attention paid to educative aspects (i.e. advance care directives and surrogate decision makers, discussion of treatment options and determining goals of care). Psychosocial interventions (i.e. quality of life beyond symptom management, including emotional/spiritual support and family and bereavement support) received limited attention in the literature, though there was some recognition that psychosocial interventions should be part of end-of-life care provision. Given the focus on the prominent disease presentation of liver cirrhosis and/or end-stage liver disease, the social and cultural dimensions of these infections have received less attention in the literature on end-of-life in the context of chronic viral hepatitis.

People engaged in opioid agonist treatment as a counterpublic during the COVID-19 pandemic in Australia: A qualitative study

INTRODUCTION

People receiving opioid agonist treatment (OAT) are at higher risk of comorbidities, poverty and discrimination, which Big Events like the COVID-19 pandemic may exacerbate. The behaviours of people receiving OAT do not always align with normative behaviours as conceived by ruling institutions and laws, and so the group becomes a counterpublic, not imagined in mainstream public discourse. The aim of this study was to understand how people receiving OAT, as a counterpublic, implemented practises of care to mitigate negative health outcomes during COVID-19.

METHODS

Participants were recruited via eight peer-led organisations across Australia. In-depth, semi-structured interviews were completed between August and December 2020 with 40 people receiving OAT. The analysis centres practises of care, allowing interactions that influence the health of participants, to be understood in their unique contexts.

RESULTS

Aspects of the COVID-19 state response were designed for an idealised public, demonstrated by the increased policing that accompanied enforcement of restrictions which was detrimental to the wellbeing of people receiving OAT. Counterpublic health strategies employed by people receiving OAT were disrupted, but participants were often able to adapt to the changing context.

DISCUSSION AND CONCLUSION

This study elucidates how practises of care among people receiving OAT are enacted and disrupted during a Big Event, with implications beyond the COVID-19 pandemic for future Big Events. The study findings evidence the need for policies that mitigate the impact of Big Events such as supporting re-groupment within the counterpublic, legitimising counterpublic health strategies and stopping the criminalisation of people who use drugs.

Future destinations and social inclusion scoping review: how people cured of hepatitis C (HCV) using direct- acting antiviral drugs progress in a new HCV-free world

BACKGROUND

There has been a paradigm shift in the treatment of Hepatitis C (HCV) from the interferon-era to direct-acting antiviral (DAA) drugs. Cure of HCV for the key risk group, those with a history of injecting drug use, may provide a range of benefits to an individual's quality of life that can be additional to that of a clinical cure. The interferon-era provided evidence that cure of HCV can be a turning point for those who use drugs, supporting a recovery journey. There remains a question if DAAs can provide the same opportunity.

METHODS

We employed a scoping review methodology to consider the additional non-clinical benefits that HCV cure may provide. We used the theoretical construct of recovery capital to consider how these benefits may support a recovery journey in the DAA-era.

RESULTS

Our search provided 2095 articles, from which 35 were included in the analysis. We developed a thematic synthesis of the non-clinical outcomes identified based on the four over-arching themes of recovery capital: physical, cultural, social and human capital. Our review suggests that identity change is a constituent part of each of the recovery capital domains in relation to HCV treatment.

CONCLUSION

We identified Social Identity Model Of Recovery (SIMOR) as a mechanism through which DAAs may provide non-clinical outcomes to increase recovery capital domains. Further research is required to develop an understanding of the impact a cure of HCV with DAAs may have on identity, overall health and wellbeing and social inclusion to support recovery journeys.

Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review protocol

INTRODUCTION

Hepatitis C virus (HCV) is a strongly stigmatised disease as it is framed within the context of injecting substance use. HCV provides the identity of 'dirty' or 'junky', with perceptions by others being beyond the control of the individual. People who experience problematic substance use are often viewed as being outside acceptable social behaviours, thus viewed as having tainted identities or second-class citizens. It is suggested that to recover from substance use, people should move towards social networks where substance use is not the norm and there is greater recovery support. The social identity model of recovery advocates that the mechanism to do this is by developing a new identity. It is unclear what catalysts provide this change in identity. This systematic review aims to describe actions, interventions and treatments that provide the opportunity for new identities and considers evidence that supports the hypothesis that curing HCV with direct acting antivirals may provide this opportunity.

METHODS AND ANALYSIS

Methods are informed by the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Seven electronic peer-reviewed and four grey literature sources were identified and preliminary searches have been conducted. The inclusion and exclusion criteria are broad to capture activities that result in a change in identity, recovery from substance use, quality of life, life satisfaction or the opportunity for the individual to reclaim their place in society (citizenship). Qualitative and quantitative literature are eligible. Papers will be assessed against standardised criteria and checked independently and in duplicate. A narrative synthesis of the findings will be reported, structured around intervention type, population context and outcomes.

ETHICS AND DISSEMINATION

This systematic review will be based on studies that have already been conducted and therefore no ethical approvals are required. The resulting findings will be submitted to an international peer-reviewed journal and disseminated at relevant research conferences.

PROSPERO REGISTRATION NUMBER

CRD42020209447.

Becoming posthuman: hepatitis C, the race to elimination and the politics of remaking the subject

Hepatitis C has long been a public health problem in Australia. 'Revolutionary' new drugs with the potential to cure hepatitis C have now emerged. The Australian government has invested heavily in them, and has an ambitious goal to eliminate hepatitis C by 2030. Numerous shifts in policy and practice are required if the elimination agenda is to be realised. This paper explores the significance of these shifts. We ask: what is the race to elimination doing with the subject? We argue that the race to elimination can be understood, simultaneously, as a product of posthuman forces, capable of being analysed using the theoretical tools made available via the posthuman turn; producing an intervention in what it means to be human; and generating a dilemma for people who use (or used) drugs, people with hepatitis C, and posthuman scholarship. In drawing out these issues, we aim to: trace the significant developments underway in hepatitis C medicine and raise awareness of them; encourage reflection on the consequences of these developments; and invite reflections on what might be lost when the human is remade by hepatitis C medicine.

Online interventions to reduce stigma towards population groups affected by blood borne viruses in Australia

BACKGROUND

Stigmatising attitudes and behaviours by others can have a range of negative effects for population groups and individual people affected by blood borne viruses. The reduction of stigma is a major goal within current Australian national health strategies, however, there is a lack of evidence regarding effective interventions to achieve this goal. Drawing on Allport's (1954) intergroup contact theory, this study aimed to evaluate the effectiveness of an online stigma reduction intervention implemented with the Australian public.

METHODS

The study was conducted between February and May 2020. Australian adults recruited via Facebook advertising were randomly allocated to a control group (n=316) or one of five intervention groups: people living with HIV (n=320), people living with hepatitis C (n=347), people living with hepatitis B (n=333), people who inject drugs (n=316), or sex workers (n=296). Participants viewed a short video depicting lived experiences of their assigned group. Participants completed attitudinal measures about the group before and immediately after the video, and then at three-month follow-up. These measures related to overall attitudes towards the group, controllability of the stigmatised condition/behaviour, desire to maintain personal distance from the group, and opinions regarding treatment of the group in health care and public policy. Longitudinal changes in attitudes were analysed using a mixed effects regression model with maximum likelihood estimation.

RESULTS

Across each of the intervention groups, reductions in negative attitudes were found immediately after watching the videos on almost all outcome measures. By three-month follow-up, the HIV intervention group demonstrated long-term improvements in relation to personal distance compared to the control group, and the hepatitis B intervention group demonstrated long-term improvements in relation to attitudes and personal distance compared to the control group. Across intervention and control groups, long-term reductions in negative attitudes were found in relation to HIV controllability, hepatitis B controllability and opinions, hepatitis C controllability and opinions, and injecting drug use attitudes and opinions.

CONCLUSION

Brief online videos depicting priority populations groups demonstrated positive results in terms of reducing some stigmatising attitudes towards those groups amongst members of the Australian public. Online contact interventions have the potential to be scaled up and rolled out across jurisdictions at national and international levels. These findings suggest that these interventions could be an effective way to contribute to the reduction of stigma and discrimination towards populations affected by blood borne viruses.

Declines in Depressive Symptoms Among People who Inject Drugs Treated With Direct-Acting Antivirals While on Opioid Agonist Therapy

Background

Hepatitis C virus (HCV) frequently co-occurs with symptoms of depression, which are aggravated on interferon-based regimens. However, it is unknown whether HCV treatment with direct-acting antivirals (DAAs) has effects on depressive symptoms among people who inject drugs (PWID). In this study, we examined changes in depressive symptoms during and after HCV treatment among PWID on opioid agonist therapies (OATs).

Methods

Participants were 141 PWID who achieved sustained viral response after on-site HCV treatment at 3 OAT programs.

Depressive symptoms were assessed using the Beck Depression Inventory–II (BDI-II) at baseline, every 4 weeks during treatment, and 12 and 24 weeks after treatment completion. Current diagnosis of depression or other psychiatric diagnoses were obtained through chart review. Use of illicit drugs was measured by urine toxicology screening. Alcohol use was measured using the Addiction Severity Index–Lite.

Results

Of the 141 PWID infected with HCV, 24.1% had severe, 9.9% had moderate, 15.6% had mild, and 50.4% had minimal levels of depression as per BDI-II scores at baseline. HCV treatment was significantly associated with reductions in depressive symptoms that persisted long term, regardless of symptom severity (P < .001) or presence of depression (P ≤ .01) or other psychiatric diagnoses (P ≤ .01) at baseline. Concurrent drug use (P ≤ .001) or hazardous alcohol drinking (P ≤ .001) did not interfere with reductions in depressive symptoms.

Conclusions

Depressive symptoms are highly prevalent among HCV-infected PWID. HCV treatment was associated with sustained reductions in depressive symptoms. HCV therapy with DAAs may have important implications for PWID that go beyond HCV cure.

HCV treatment barriers among HIV/HCV co-infected patients in the US: a qualitative study to understand low uptake among marginalized populations in the DAA era

BACKGROUND

Well-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake.

METHODS

In 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns.

RESULTS

Conditions of poverty-specifically, meeting basic needs for food, shelter, and safety-undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era.

CONCLUSIONS

Interferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.

The balancing perspective of hard-to-reach hepatitis C patients who were lost to follow-up: A qualitative study

Background

In the foreseeable future, patients with hepatitis C virus (HCV) with good healthcare access will all have been cured and the lost to follow-up (LFU) HCV-population will increasingly exist of hard-to-reach patients. Efforts to retrieve these individuals with HCV have been moderately successful so far. A deeper understanding of the reasons for loss to follow-up and the underlying processes is lacking.

Aims

To explore reasons for previous loss to follow-up in patients with HCV who have been brought back into care.

Methods

In 2017, fifteen patients with HCV who were evaluated at the University Medical Center Utrecht (UMCU) Infectious diseases outpatient clinic as part of the “REtrieval And cure of Chronic Hepatitis C” (REACH)-project were included in this study through convenience sampling. Face-to-face semi-structured in-depth interviews were conducted and a qualitative analysis based on the grounded theory was applied.

Results

A basic socio- psychological process named “maintaining the achieved balance” was uncovered in patients with HCV who were LFU. This “achieved balance” is the result of a transformative process following the initial HCV diagnosis. It is a steadfast stance in which participants keep HCV out of sight and in the margin of their lives in order to reestablish an optimal state of well-being. The balancing perspective is subsequently defended by repeated evasive behavioral patterns to avoid confrontation with the disease.

Conclusion

The balancing perspective gives insight into why individuals with HCV were not retained in care but also why they remained LFU thereafter. Physicians should realize that this mindset can be persistent and repeated efforts may be needed to finally trace and retrieve these patients.

Balance, Capacity, and the Contingencies of Everyday Life: Narrative Etiologies of Health Among Women in Street-Based Sex Work

There is an abundance of health research with women in street-based sex work, but few studies examine what health means and how it is practiced by participants. We embrace these tasks by exploring how a convenience sample of sex workers (n = 33) think about and enact health in their lives. Findings reveal pluralistic notions of health that include neoliberal, biomedical, and lay knowledge. Health is operationalized through clinic/hospital visits and self-care practices, which emerge as pragmatic behaviors and ways to resist or compensate for exclusionary treatment in health care systems. Participants also use symbols of biomedical authority to substantiate their lay interpretations of certain conditions, revealing complex forms of moral reasoning in their health etiologies. We conclude that doing health and constructing rich narratives about it are constituent elements of the women's everyday praxis and subjectivities in relation to the broader socioeconomic and political worlds of which they are a part.

Migration to the US among rural Puerto Ricans who inject drugs: influential factors, sources of support, and challenges for harm reduction interventions

BACKGROUND

While PWID of Puerto Rican origin have been migrating to the US for decades, the range of factors influencing their migration to the US and the resources they draw on to do so are not well understood. This is particularly true for rural Puerto Rican PWID, and the present study is the first empirical research to document migration patterns among this population. The specificities of their migration raise important challenges that need to be documented in order to implement more effective harm reduction policies at home (Puerto Rico) and abroad (US).

METHODS

This paper draws from data obtained employing a modified NHBS survey which was administered to (N =296) PWID in four rural municipalities of Puerto Rico with participants 18 years or older. The primary dependent variables for this paper are the number of times a person has lived in the continental US, and if they are planning on moving to the continental US in the future.

RESULTS

Findings suggest that 65% of the sample reported ever lived in the US and that 49% are planning on moving in the future. The number of times living in the US is associated with higher education and older age, but not with self-reported positive HIV or HCV statuses. Planning to move to the US is associated with knowing PWID who have moved or plan to move, negatively associated with age, and is not associated with HIV or HCV status. Around one third of those that lived in the US reported having some sort of support, with the majority receiving support from family sources. No participant received help to enter HIV/HCV treatment.

CONCLUSIONS

A multi-region approach to prevention is required to make a dent in curbing HIV/HCV transmission in this population. Understanding PWID migration patterns, risk behaviors, and health care needs in the US is now more important than ever as natural disasters prompted by human-made climate change will only increase in the future, raising demands not only for service providers but also harm reduction policies to cope with an increasing influx of "climate refugees" as PWID move across national borders.

Exploring the emotions of patients undergoing therapy for hepatitis C

BACKGROUND

direct-acting antiviral (DAA) therapy is highly efficacious in the treatment of hepatitis C (HCV). The literature to date has focused primarily on the physical health benefits of viral eradication.

AIMS

this study explored patient emotions during and after DAA therapy for HCV.

METHODS

over a 6-month period, 178 patients attending a viral hepatitis clinic for treatment of HCV were posed a single question: 'How do you feel about your diagnosis of hepatitis C today?' Responses were transcribed verbatim, thematically coded and visualised using WordArt software.

FINDINGS

the images depict the evolution of patients' perceptions of HCV before, during and after DAA therapy. Responses before treatment were predominantly negative, often describing the fear of contagion and feelings of isolation, secrecy and loneliness. After treatment, patients often described feeling positive and more motivated.

CONCLUSIONS

the results demonstrate that treatment of HCV has a transformative effect on patients' perception of the impact of HCV on their wellbeing. This may promote a more positive outlook and, in turn, facilitate patient engagement with healthcare.

Acceptability of Patient-Reported Outcome and Experience Measures for Hepatitis C Treatment Among People Who Use Drugs

BACKGROUND

Growing international interest in mechanisms to capture and measure experiences and outcomes of health interventions from the patient perspective has led to the development of patient-reported measures (PRMs) across many areas of medicine. Although PRMs are now well utilised in some settings, the rapidly expanding area of direct-acting antiviral (DAA) treatments for hepatitis C has received remarkably little attention. In addition, questions are also being raised about the extent to which patients have been involved in the development of PRMs, which are primarily designed to reflect the patient perspective. In this context, the aim of this paper was to explore the possibility of developing a new PRM for use in hepatitis C DAA therapy that would also be acceptable to the patient group, in this case people who inject drugs (PWID).

METHOD

The study was based on a participatory design that included a peer researcher and foundational qualitative research including semi-structured interviews with 24 PWID with hepatitis C to inform the development of the PRMs. Stage 2 included four focus groups of six PWID with hepatitis C, who were asked to complete the draft measures and provide feedback.

RESULTS

Participants responded positively to the draft PRMs. The results indicate that participants' concerns during DAA treatment are often not sufficiently attended to in clinical settings. In the light of this finding, participants reported that PRMs have a positive role to play in the negotiation of patients' care during DAA treatment.

CONCLUSIONS

The findings show that utilising a participatory approach to the development of PRMs for DAA HCV treatment with PWID not only provides a way to measure experiences and outcomes of treatment from the patient perspective, but also provides a means for highly marginalised patient groups to have a say in and negotiate their care in ways that might not otherwise be possible.

Experiences of diagnosis, stigma, culpability and disclosure in male patients with hepatitis C virus: An interpretative phenomenological analysis

The current study aimed to explore the lived experience of patients with hepatitis C virus infection. Semi-structured interviews were conducted with seven male participants living with hepatitis C virus and were analysed using interpretative phenomenological analysis. Two master themes were identified: (1) diagnosis and the search for meaning and (2) impact of stigma on disclosure. Participants reported fears of contaminating others, feelings of stigma and concerns of disclosing the condition to others. Response to diagnosis, stigma and disclosure among the participants appeared to be interrelated and directly related to locus of blame for virus contraction. More specifically, hepatitis C virus transmission via medical routes led to an externalisation of culpability and an openness to disclosure. Transmission of hepatitis C virus as a direct result of intravenous drug use led to internalised blame and a fear of disclosure. The inter- and intra-personal consequences of hepatitis C virus explored in the current study have potential implications for tailoring future psychological therapy and psychoeducation to the specific needs of the hepatitis C virus population.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

The experiences of people who inject drugs of skin and soft tissue infections and harm reduction: A qualitative study

BACKGROUND

Bacterial skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are considered a public health concern. There is a lack of qualitative research examining the lived experience of PWID who have had SSTI. This paper explores PWID views and experiences of their SSTI, their perceptions on the causes of their SSTI and their harm reduction (HR) behaviours. The implications for HR service delivery and practice will be discussed.

METHODS

Between October 2015-January 2016, 22 in-depth interviews were conducted with PWID who had experienced a SSTI within the past year. Interviewees were recruited from an injecting equipment provision service and a drug treatment service in Glasgow and Edinburgh respectively. The interview transcripts were transcribed verbatim and underwent thematic analysis.

RESULTS

We found that the experience of SSTI can cause strong negative feelings, including panic and stigma and that there was limited knowledge of SSTI prior to first hand experience. The awareness of the unacceptable social and physical consequences of SSTI fostered a sense of personal responsibility and agency which led to the introduction or improved HR uptake. However, when PWID were struggling to inject or when their physical and political environments were compromised there was an increased risk for SSTI and reduced effectiveness of HR.

CONCLUSION

Compared to HCV and HIV, SSTI as an injecting related harm has received less policy attention. Policy makers need to address SSTI HR within enabling environments, such as 'safer environment interventions'. It is recommended that peer based support, improved NSP provision and medically supervised injecting facilities are needed to deliver SSTI HR.

Associating conditional cash transfer to universal access to treatment could be the solution to the HCV epidemic among drug users (DUs)

Background

To understand the limits of HCV screening programs to reach all drug users (DUs).

Method

The association of the recruitment of a representative sample of a population of DUs in a specific area with the use of a questionnaire that included 250 items allowed the use of uni- and multifactorial analysis to explore the relationship between HCV screening and dimensions until now restricted to qualitative studies.

Results

We recruited, in less than 2 months, 327 DUs representing about 6% of the total population of DUs. They belonged to a single community whose drug use was the only common characteristic. While almost all DUs (92.6%) who had access to care providers had been screened, this proportion was much lower in out-of-care settings (64%). HCV prevalence among those who had performed a test was low (22.8%). For DUs, the life experience of hepatitis C has not changed in the last 10 years. Screening, studied for the first time according to this life experience, was not influenced by a rational knowledge of the risk taken or the knowledge of treatment efficacy, showing a gap between DUs’ representations and medical recommendations which explains the low level of active screening. Police crackdown on injections, disrupting the previous illusion of safe practices, was the only prior history leading to active screenings. Screenings were related to an access to care providers. GPs held a preponderant position as a source of information and care by being able to give appropriate answers regarding hepatitis C and prescribing opioid substitution treatments (OST). If 48 % of DUs screened positive for HCV had been treated, half of them had been prescribed before 2006.

Conclusion

While hepatitis has become a major issue for society and, consequently, for services for DUs (SDUs) and GPs, it is not the case for DUs. A widespread screening, even in a city where the offer of care is diversified and free, seems unlikely to reach a universal HCV screening over a short time. The model of respondent-driven sampling recruitment could be a new approach to conditional cash transfer, recruiting and treating DUs who remain outside the reach of care providers, a prerequisite for the universal access to HCV treatments to impact the HCV epidemic.

Beyond cure: patient reported outcomes of hepatitis C treatment among people who inject drugs in Australia

Background

Recent advances in the treatment of hepatitis C virus (HCV) infection provide the possibility of eliminating HCV as a public health threat. This focus on HCV elimination through treatment, however, is also driving a concomitant focus on ‘achieving cure’ as the primary outcome of treatment. The aim of this paper is to explore what people who inject drugs consider to be important in relation to outcomes of HCV treatment, and whether there are outcomes ‘beyond cure’ that might be important to understand as part of improving engagement in treatment.

Methods

A peer researcher with experience of both HCV treatment and injecting drug use conducted interviews with 24 people in the following groups in Melbourne, Australia: (1) people who had refused or deferred HCV treatment; (2) people who were actively thinking about, planning and/or about to commence HCV treatment; (3) people currently undertaking HCV treatment and (4) people who had recently completed HCV treatment.

Results

The findings show that people who inject drugs are seeking outcomes ‘beyond cure’ including improved physical and mental health, positive changes in identity and social relationships and managing future health and risk. Participants indicated that these other outcomes had not been addressed within their experience of HCV treatment.

Conclusion

While cure is an obvious outcome of HCV treatment, patients are seeking change in other areas of their lives. This study also provides valuable insights for the development of patient-reported measures in this context, which would be an important step towards more patient-centred approaches to HCV treatment.

Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes

BACKGROUND

The development of simplified and effective hepatitis C (HCV) pharmaceuticals enables treatment scale up among the most marginalised. This potentiates a promise of viral elimination at the population level but also individual level clinical and non-clinical benefits. Reports of transformative non-clinical outcomes, such as changes in self-worth and substance use, are primarily associated with arduous interferon-based treatments that necessitate intensive care relationships. We consider the implications of simplified treatment provision in the era of direct acting antivirals (DAAs) for the realisation of non-clinical benefits.

METHODS

We draw on qualitative data from ethnographic observations and longitudinal interviews with people receiving (n = 22) and providing (n = 10) HCV treatment in London during a transition in HCV biomedicine. First generation DAAs in conjunction with interferon were standard of care for most of this time, with the promise of simplified treatment provision on the horizon.

FINDINGS

Patient accounts of care accentuate the transformative value of interferon-based HCV treatment derived through non-clinical benefits linked to identity and lifestyle change. Such care is constituted as extending beyond the virus and its biomedical effects, with nurse specialists positioned as vital to this care being realised. Provider accounts emphasise the increased pharmaceuticalisation of HCV treatment; whereby care shifts from the facilitation of therapeutic relationships to pharmaceutical access.

CONCLUSION

HCV care in the interferon-era affords identity transformations for those receiving and providing treatment. Biomedical promise linked to the increasing pharmaceuticalisation of HCV treatment has disruptive potential, shifting how care is practised and potentially the realisation of non-clinical treatment outcomes.

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

The United Kingdom has committed to eliminating viral hepatitis as a public health threat. Innovative interventions for marginalized populations are required to realize this goal. In 2016, the HepCATT study team implemented a complex hepatitis C (HCV) intervention in three English drug treatment services, with five controls. We report qualitative study findings from two intervention sites to explore intervention success and transferability potential. The intervention comprised multiple components, including a nurse facilitator, peer support and education initiatives. Qualitative data were generated at baseline (2014) and post-intervention (2016) at two sites through in-depth interviews, focus groups and observations. The 96 participants comprised drug service and intervention providers and clients with an injecting history. Data were triangulated and thematically analysed. Client engagement with a HCV treatment service rose from 16 at baseline to 147 in 2016. There was no comparable increase at the five control sites. Baseline testing and treatment barriers included the following: limited HCV knowledge; fear of diagnosis and treatment; precarious living circumstances and service-specific obstacles. Treatment engagement was aided by intervention timeliness; improved communication structures; personalized care; streamlined testing and treatment pathways; peer support. Multiple interrelated components influenced the increased levels of treatment engagement documented in HepCATT. The nurse facilitator, involved in implementation and innovation, was key to intervention success. Baseline barriers correspond with international literature-indicating transferability potential. Control data indicate that biomedical innovation alone is not sufficient to increase engagement among the most marginalized. Sustainable resourcing of community services is crucial to effect change.

A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK

Background

Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK.

Methods

A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses.

Results

We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation.

Conclusions

The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.

Experiences of liver health related uncertainty and self-reported stress among people who inject drugs living with hepatitis C virus: a qualitative study

BACKGROUND

People who inject drugs (PWID) are most at risk of hepatitis C virus infection in Australia. The introduction of transient elastography (TE) (measuring hepatitis fibrosis) and direct acting antiviral medications will likely alter the experience of living with hepatitis C. We aimed to explore positive and negative influences on wellbeing and stress among PWID with hepatitis C.

METHODS

The Treatment and Prevention (TAP) study examines the feasibility of treating hepatitis C mono-infected PWID in community settings. Semi-structured interviews were conducted with 16 purposively recruited TAP participants. Participants were aware of their hepatitis C seropositive status and had received fibrosis assessment (measured by TE) prior to interview. Questions were open-ended, focusing on the impact of health status on wellbeing and self-reported stress. Interviews were voice recorded, transcribed verbatim and thematically analysed, guided by Mishel's (1988) theory of Uncertainty in Illness.

RESULTS

In line with Mishel's theory of Uncertainty in Illness all participants reported hepatitis C-related uncertainty, particularly mis-information or a lack of knowledge surrounding liver health and the meaning of TE results. Those with greater fibrosis experienced an extra layer of prognostic uncertainty. Experiences of uncertainty were a key motivation to seek treatment, which was seen as a way to regain some stability in life. Treatment completion alleviated hepatitis C-related stress, and promoted feelings of empowerment and confidence in addressing other life challenges.

CONCLUSION

TE scores seemingly provide some certainty. However, when paired with limited knowledge, particularly among people with severe fibrosis, TE may be a source of uncertainty and increased personal stress. This suggests the need for simple education programs and resources on liver health to minimise stress.

Consumer agency in cannabis supply - Exploring auto-regulatory documents of the cannabis social clubs in Spain

BACKGROUND

There is growing experience with the not-for-profit, consumer-driven cannabis social club (CSC) model that builds on self-supply, self-organization and harm-reduction; these are principles upon which people who use drugs (PWUD) have been engaging for decades. Recent legalization of cannabis in a number of jurisdictions and the related challenges in regulating production, sale, taxation and health-related matters have raised interest in non-commercial models of cannabis supply. The "codes of conduct" (CsoC) of CSC federations in Spain might reveal whether a consumer-based model could overcome these challenges.

METHODS

To examine the content of the CSC auto-regulatory documents, an online search using key terms to identify the CsoC was conducted. Six documents were found; analysis of the main thematic categories and overarching themes was conducted. It was discussed how these corresponded to the areas of cannabis policy regulation and what the main limitations of the CSC model were.

RESULTS

The CsoC detailed the rules for CSC administration, not-for-profit aims, "invitation only" and other conditions of membership, collective cultivation and security as well as for operation of the consumption venue and health-related initiatives. The themes in the CsoC overlapped with cannabis regulatory areas as outlined internationally. Concern over cannabis prices and potency was missing in the CsoC. The potential strengths of the CSC model might include safe environment for peer-delivered harm reduction practice, preventing illicit transactions, quality control, shifting economic surplus to the consumers and increased consumer responsibility. The limitations of the CSC model include high threshold, disguised motives, tax revenue and the risk of both under- and over-regulation.

CONCLUSION

CSCs represent an opportunity to enhance consumer agency and responsibility. The right "to be self-supplied" with psychoactive substances can be granted to consumer associations - but authorities need to provide a framework to facilitate this voluntary self-organization, including minimum standards around public health and safety, and to involve consumers in the development of these regulations.

'Sussing that doctor out.' Experiences and perspectives of people affected by hepatitis C regarding engagement with private general practitioners in South Australia: a qualitative study

BACKGROUND

Australians with chronic hepatitis C (HCV) can access affordable Direct Acting Antiviral (DAA) treatments with high cure rates (>90%), via General Practitioners (GPs). Benefits from this treatment will be maximised if people with HCV readily disclose and engage with private GPs regarding HCV-related issues. Investigating the perceptions and experiences of people affected by HCV with GPs can allow for this pathway to care for HCV to be improved.

METHODS

In 2013-2014, 22 purposively sampled participants from South Australia (SA) were interviewed. They a) had contracted or were at risk of hepatitis C (n = 10), b) were key workers who had clients affected by HCV (n = 6), and c) met both a) and b) criteria (n = 6). The semi-structured interviews were recorded, transcribed and thematically analysed.

RESULTS

People affected by HCV viewed GPs as a source of general healthcare but, due to negative experiences and perceptions, many developed a strategy of "sussing" out doctors before engaging with and disclosing to a GP regarding HCV-related issues. Participants were doubtful about the benefits of engagement and disclosure, and did not assume that they would be provided best-practice care in a non-discriminatory, non-judgemental way. They perceived risks to confidentiality and risks of changes to the care they received from GPs upon disclosure.

CONCLUSION

GPs may need to act in ways that counteract the perceived risks and persuade people affected by HCV of the benefits of seeking HCV-related care.

Hepatitis C in a new therapeutic era: Recontextualising the lived experience

AIMS AND OBJECTIVES

To explore the experience of adults living with hepatitis C in a new era of interferon-free treatment.

BACKGROUND

Hepatitis C is a leading cause of morbidity and mortality worldwide, posing a significant challenge to global public health. Historically, the treatment of hepatitis C was poorly efficacious and highly demanding; however, more effective and tolerable therapies have become available in high-income nations in recent years. This is the first study to explore how these significant developments in the treatment of hepatitis C may have influenced the experience of those living with the virus, and their understanding of the disease.

DESIGN

A qualitative study underpinned by social phenomenological theory.

METHODS

Data were generated through semi-structured interviews with a purposive sample of 20 hepatitis C positive adults living in a large city in Scotland.

RESULTS

Thematic analysis identified three overriding themes. "Positioning hepatitis C" illustrated how the disease was understood within wider sociocultural, medical and politico-economic contexts. "Beyond a physical burden" emphasised the emotional aspect of infection, and "a new uncertainty" revealed participants' cautious response to the advances in hepatitis C therapy.

CONCLUSIONS

Interthematic discourse portrayed the new era of hepatitis C treatment as holding little sway over constructions of the illness, as narratives resonated with previous studies. Such unmoving "lay" understandings of hepatitis C may pose potential barriers to the new therapeutic era from reaching its full potential.

RELEVANCE TO CLINICAL PRACTICE

How people living with the virus perceive and understand hepatitis C can have an adverse impact on their engagement with care and treatment. Whilst global medical discourse eulogises the arrival of a new era of therapy, there remain significant challenges for nurses engaging those with hepatitis C in therapeutic pathways.

Integrated opioid substitution therapy and HIV care: a qualitative systematic review and synthesis of client and provider experiences

People who use drugs in many contexts have limited access to opioid substitution therapy and HIV care. Service integration is one strategy identified to support increased access. We reviewed and synthesized literature exploring client and provider experiences of integrated opioid substitution therapy and HIV care to identify acceptable approaches to care delivery. We systematically reviewed qualitative literature. We searched nine bibliographic databases, supplemented by manual searches of reference lists of articles from the database search, relevant journals, conferences, key organizations and consultation with experts. Thematic synthesis was used to develop descriptive themes in client and provider experiences. The search yielded 11 articles for inclusion, along with 8 expert and policy reports. We identify five descriptive themes: the convenience and comprehensive nature of co-located care, contrasting care philosophies and their role in shaping integration, the limits to disclosure and communication between clients and providers, opioid substitution therapy enabling HIV care access and engagement, and health system challenges to delivering integrated services. The discussion explores how integrated opioid substitution therapy and HIV care needs to adapt to specific social conditions, rather than following universal approaches. We identify priorities for future research. Acceptable integrated opioid substitution therapy and HIV care for people who use drugs and providers is most likely through co-located care and relies upon attention to stigma, supportive relationships and client centred cultures of delivery. Further research is needed to understand experiences of integrated care, particularly delivery in low and middle income settings and models of care focused on community and non-clinic based delivery.

Is disclosure a privilege? Race and disclosure patterns of hepatitis C

Research suggests that decisions to disclose hepatitis C status are affected by individual and interpersonal factors. However, no existing studies have examined the role of race in disclosure, despite the potential implications of being doubly marginalized on the basis of both race and hepatitis C status. Drawing on qualitative research with 53 persons with hepatitis C in the Southeastern United States, findings indicate that participants practiced four patterns of disclosure: activist disclosure, open disclosure, limited disclosure, and reluctant disclosure. The majority of African Americans in this research practiced limited and reluctant disclosure, while Whites' disclosure patterns were more varied. These findings suggest that race shapes patterns of disclosure of hepatitis C, which has important implications for prevention, help seeking, social support, exposure to discrimination, and addressing racial disparities in health.

Living with Hepatitis C Virus: A Systematic Review and Narrative Synthesis of Qualitative Literature

Background and Aims. The lived experience of HCV has not been well documented in the literature. The aim of this systematic review was to understand the experiences of living with Hepatitis C Virus (HCV). Methods. Five databases were searched from inception until January 19, 2015. Studies were included if they focused on adults diagnosed with HCV; reported experience living with HCV; and described original research. Results. 46 studies were included. Studies found that participants had reduced quality of life due to physical symptoms. Due to physical symptoms and discrimination, many participants switched to part-time work or quit their jobs. Many individuals reported negative experiences with the healthcare system; themes of feeling unsupported, not having adequate information, and not feeling involved in decisions were reported. Stigma significantly impacted those living with HCV. Conclusions. Published literature indicates that those with HCV often feel stigmatized and unsupported in their care, relationships, and work environments, while simultaneously coping with physical and psychological symptoms. This synthesis points to areas where greater education, compassion, and patient-centered healthcare could improve the experience of people living with HCV.

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Urgent action to fight hepatitis C in people who inject drugs in Europe

Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver cancer, is curable in most people. Injecting drug use currently accounts for 80 % of new HCV infections with a known transmission route in the European Union (EU). HCV has generally received little attention from the public or policymakers in the EU, with major gaps in national-level strategies, action plans, guidelines and the evidence base. Specifically, people who inject drugs (PWID) are often excluded from treatment owing to various patient, healthcare provider and health system factors. All policymakers responsible for health services in EU countries should ensure that prevention, treatment, care and support interventions addressing HCV in PWID are developed and implemented. According to current best practice, PWID should have access to comprehensive, evidence-based multiprofessional harm reduction (especially opioid substitution therapy and clean needles and syringes) and support/care services based in the community and modified with community involvement to accommodate this hard-to-reach population. Other recommended components of care include vaccination against hepatitis B and other infections; peer support interventions; HIV testing, prevention and treatment; drug and alcohol services; psychological care as needed; and social support services. HCV testing should be performed regularly in PWID to identify infected persons and engage them in care. HCV-infected PWID should be considered for antiviral treatment (based on an individualised assessment and delivered within multidisciplinary care/support programmes) both to cure infected individuals and prevent onward transmission. Modelling data suggest that the HCV disease burden can only be cut substantially if antiviral treatment is scaled up together with prevention programmes. Measures should be taken to reduce stigma and discrimination against PWID at the provider and institutional levels. In conclusion, strategic action at the policy level is urgently needed to increase access to HCV prevention, testing and treatment among PWID, the group at highest risk of HCV infection. Such action has the potential to substantially reduce the number of infected persons, along with the disease burden and related care costs.

The stigmatisation of 'ice' and under-reporting of meth/amphetamine use in general population surveys: A case study from Australia

BACKGROUND AND AIMS

Stigmatisation of illicit drug use is known to discourage people from reporting their use of illicit drugs. In the context of Australia's two recent "ice-epidemics" this study examines whether rapid increases in community concern about meth/amphetamine concurrent with increased stigmatising media reporting about meth/amphetamine "epidemics" are associated with increased under-reporting of its use in population surveys.

METHODS

We examined the relationship between general population trends in self-reported lifetime use of and attitudes towards meth/amphetamine between 2001 and 2013, contextualised against related stimulants and heroin, using five waves of Australia's National Drug Strategy Household Survey (NDSHS), alongside trends in print media reporting on meth/amphetamine from 2001 to 2014.

RESULTS

Analysis of NDSHS data showed significant increases in community concern about meth/amphetamine between 2004 and 2007, and 2010 and 2013 in all birth cohorts and age groups. In both periods self-reported lifetime use of meth/amphetamine fell in many birth cohorts. The falls were only statistically significant in the first period, for birth cohorts from 1961-1963 to 1973-1975. Falls in lifetime use within a cohort from one period to the next are incongruous and we did not observe them in the other drugs considered. Equally, increases in concern were specific to meth/amphetamine. We counted substantial and rapid increase in the number of newspaper reports about meth/amphetamine in both periods, particularly reports including the term 'epidemic'.

CONCLUSIONS

Rapid increases in the quantum of media reporting stigmatising a drug (through its construction as an 'epidemic') accompanying increased general public concerns about the drug may increase the tendency to under-report lifetime use. This may make it difficult to rely upon household surveys to observe trends in patterns of use and suggests that policy makers, media and others in the AOD sector should avoid stigmatisation of drugs, particularly during periods of heightened concern.

Listening to both sides: A qualitative comparison between patients with hepatitis C and their healthcare professionals' perceptions of the facilitators and barriers to hepatitis C treatment adherence and completion

This qualitative study compares and contrasts the perspectives of healthcare professionals who treat hepatitis C with those of patients in treatment. Comparative analysis of semi-structured interviews with 20 healthcare professionals and 20 patients undergoing treatment for hepatitis C concluded that patients and healthcare professionals disagreed on the source of communication breakdowns, but both felt that individualised clinical information improved adherence. Stigma was recognised as a barrier to treatment adherence by both patients and healthcare professionals. Limitations of the healthcare system, such as patients receiving inconsistent information and long wait times, negatively impacted both patients and providers.

Pathways linking drug use and labour market trajectories: the role of catastrophic events

People affected by substance use disorders often experience sub-optimal employment outcomes. The role of drug use in processes that produce and entrench labour market precarity among people who inject drugs (PWID) have not, however, been fully described. We recruited 22 PWID from ongoing prospective cohort studies in Vancouver, Canada, with whom we conducted semi-structured retrospective interviews and then employed a thematic analysis that drew on concepts from life course theory to explore the mechanisms and pathways linking drug use and labour market trajectories. The participants' narratives identified processes corresponding to causation, whereby suboptimal employment outcomes led to harmful drug use; direct selection, where impairment, health complications or drug-seeking activities selected individuals out of employment; and indirect selection, where external factors, such as catastrophic events, marked the initiation or intensification of substance use concurrent with sudden changes in capacities for employment. Catastrophic events linking negative transitions in both drug use and labour market trajectories were of primary importance, demarcating critical initiation and transitional events in individual risk trajectories. These results challenge conventional assumptions about the primacy of drug use in determining employment outcomes among PWID and suggest the importance of multidimensional support to mitigate the initiation, accumulation and entrenchment of labour market and drug-related disadvantage.

Jugular venipuncture and other innovative approaches to phlebotomy among people who inject drugs

In their recent paper on patient experiences of accessing phlebotomy services in hospital outpatient clinics, Clements and colleagues state that there is a real need to better understand the responses of people who inject drugs to phlebotomy. They discuss the reasons why people who inject drugs might not be accessing healthcare services, especially in relation to treatment for hepatitis C. Their research is a welcome addition to the literature that emphasizes the stigma and discrimination faced by people who inject drugs, including within healthcare settings, and outlines the need to promote effective partnerships between healthcare workers and patients so as to deliver the best health outcomes.

What value is the CINAHL database when searching for systematic reviews of qualitative studies?

BACKGROUND

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) is generally thought to be a good source to search when conducting a review of qualitative evidence. Case studies have suggested that using CINAHL could be essential for reviews of qualitative studies covering topics in the nursing field, but it is unclear whether this can be extended more generally to reviews of qualitative studies in other topic areas.

METHODS

We carried out a retrospective analysis of a sample of systematic reviews of qualitative studies to investigate CINAHL's potential contribution to identifying the evidence. In particular, we planned to identify the percentage of included studies available in CINAHL and the percentage of the included studies unique to the CINAHL database. After screening 58 qualitative systematic reviews identified from the Database of Abstracts of Reviews of Effects (DARE), we created a sample set of 43 reviews covering a range of topics including patient experience of both illnesses and interventions.

RESULTS

For all 43 reviews (21 %) in our sample, we found that some of the included studies were available in CINAHL. For nine of these reviews, all the studies that had been included in the final synthesis were available in the CINAHL database, so it could have been possible to identify all the included studies using just this one database, while for an additional 21 reviews (49 %), 80 % or more of the included studies were available in CINAHL. Consequently, for a total of 30 reviews, or 70 % of our sample, 80 % or more of the studies could be identified using CINAHL alone. 11 reviews, where we were able to recheck all the databases used by the original review authors, had included a study that was uniquely identified from the CINAHL database. The median % of unique studies was 9.09%; while the range had a lowest value of 5.0% to the highest value of 33.0%. [corrected].

CONCLUSIONS

Assuming a rigorous search strategy was used and the records sought were accurately indexed, we could expect CINAHL to be a good source of primary studies for qualitative evidence syntheses. While we found some indication that CINAHL had the potential to provide unique studies for systematic reviews, we could only fully test this on a limited number of reviews, so we are less confident about this finding.

The common sense model applied to hepatitis C: a qualitative analysis of the impact of disease comparison and witnessed death on hepatitis C illness perception

BACKGROUND

Hepatitis C virus (HCV) accounts for 15,000 deaths in the United States yearly because people living with HCV are not identified in time to seek treatment, are ineligible for or refuse treatment, or face structural impediments to obtaining treatment such as lack of access to health care or lack of insurance. People who inject drugs (PWID) comprise a large proportion-estimates of up to 60-70%-of current and new HCV infected individuals and face many barriers to completing HCV treatment.

METHODS

We conducted 30 qualitative semi-structured interviews of current and former PWID seeking HCV treatment at an opioid-agonist treatment facility in New York City. We used thematic analysis, informed by grounded theory, to examine perceptions of HCV and decisions to initiate HCV treatment. We analyzed the themes that emerged via the common sense model (CSM) of illness perception theoretical framework.

RESULTS

Using thematic analyses, two major themes emerged related to engagement in HCV treatment. First, participants independently compared HCV to HIV, and in so doing, emphasized the potential fatality of HCV and the need for treatment. Second, participants described witnessing others suffer or die from untreated HCV and expressed how these recollections impacted their desire to undergo treatment themselves. Together, these themes contributed to the way participants perceived HCV and informed their decisions to initiate treatment. Both themes reflect the CSM's "self-regulation" process, which posits that understanding the causes and consequences of an illness impacts one's ability to seek treatment to overcome this illness state.

CONCLUSIONS

This paper offers insight into how clinicians can better understand and utilize HCV illness perceptions to evaluate willingness to engage in HCV treatment among PWID considering antiviral treatment modalities.

The Hepatitis C treatment experience: Patients' perceptions of the facilitators of and barriers to uptake, adherence and completion

OBJECTIVE

This study explores the perceptions of patients receiving treatment for Hepatitis C to determine what factors influence their decision to commence treatment, ability to maintain adherence and complete their treatment program.

DESIGN

Semi-structured interview techniques were used in a qualitative study of 20 patients undergoing treatment for Chronic Hepatitis C (CHC).

MAIN OUTCOME MEASURES

To explore patients' perceived barriers and facilitators of Hepatitis C treatment adherence and completion.

RESULTS

Analysis of patient interviews identified four key themes: (1) motivations for commencing CHC treatment - fear of death and ridding themselves of stigma and shame; (2) the influential role of provider communication - patients reported that information and feedback that was personalised to their needs and lifestyles was the most effective for improving adherence to treatment; (3) facilitators of treatment adherence and completion - social, emotional and practical support improved adherence and completion, as did temporarily ceasing employment; (4) barriers to treatment adherence and completion - these included side effects, stigma, a complicated dosing schedule and limitations of the public healthcare system.

CONCLUSION

To increase treatment adherence and completion rates, a patient-centred approach is required that addresses patients' social, practical, and emotional support needs and adaptive coping strategies.

Care and treatment of hepatitis C among Aboriginal people in New South Wales, Australia: implications for the implementation of new treatments

INTRODUCTION

Despite Aboriginal Australians being over-represented in populations of people living with hepatitis C (HCV), there is a dearth of research to guide policy and programme development in the area of care and treatment, particularly relating to new HCV treatments.

METHOD

In-depth interviews were conducted with 39 people identifying as Aboriginal Australians and living with HCV in New South Wales.

RESULTS

Participants' experiences were characterised by a lack of detailed or appropriate information provided at diagnosis, high levels of stigma associated with HCV and low overall knowledge of HCV as reported for themselves and their communities. Despite poor diagnosis experiences, participants had undertaken changes to their lifestyle, especially in relation to alcohol use, in order to promote liver health. Concerns about treatment side effects and efficacy impacted participants' decisions to undertake treatment. Eleven participants had undertaken HCV treatment in a variety of care models with a peer worker and in prison.

CONCLUSIONS

The similarities between concerns and experiences of Aboriginal people and other populations living with HCV do not suggest that services and strategies to engage these populations should also be the same. These results suggest that further engagement of the primary care sector in HCV care is important as well as increasing Aboriginal community knowledge of HCV. A variety of service models should be available to meet individuals' preferences, including those offered within Aboriginal community controlled health services emphasising holistic notions of health, and supported by information and communication programmes using principles of health literacy relevant to Aboriginal people.