Therapeutic challenges in hepatitis C-infected injection drug using patients

Predictors of hepatitis C treatment outcomes in a harm reduction-focused primary care program in New York City

Background

The social determinants of health that influence steps in the entire Hepatitis C Virus (HCV) treatment cascade must be identified to achieve HCV elimination goals. This project aimed to evaluate the association of these factors with HCV treatment completion and return for sustained virologic response (SVR) testing.

Methods

We used retrospective cohort data from our primary care-based HCV treatment program that provides comprehensive harm reduction care to those who use or formerly used drugs. Among persons who began direct-acting antiviral HCV treatment between December 2014 and March 2018, we identified two outcomes: HCV treatment completion and return for SVR assessment 12 weeks after treatment end. Several predictors were ascertained including sociodemographic information, substance use, psychiatric symptoms and history, housing instability, and HCV treatment regimen. We then evaluated associations between predictors and outcomes using univariate and multivariable statistical methods.

Results

From a cohort of 329 patients treated in an urban primary care center, multivariable analysis identified housing instability as a single significant predictor for HCV treatment completion (odds ratio [OR]: 0.3; 95% confidence interval [CI]: 0.1–0.9). Among patients completing treatment, 226 (75%) returned for SVR assessment; the sole predictor of this outcome was Medicaid as primary insurance (compared to other insurances; OR 0.3; 0.1–0.7).

Conclusions

Innovative strategies to help unstably housed persons complete HCV treatment are urgently needed in order to reach HCV elimination targets. Educational and motivational strategies should be developed to promote individuals with Medicaid in particular to return for SVR viral load testing, a critical post-treatment component of the HCV treatment cascade.

Trial registration Not applicable.

Hepatitis-C virus infection among injecting drug users in Lahore, Pakistan: A cross sectional study

OBJECTIVES

To determine the prevalence and risk factors of hepatitis C virus among injecting drugs users, furthermore different genotypes of HCV infection and their effect on viral load were also found and subsequently most prevalent subtype was predicted.

METHODS

All samples were processed for Anti-HCV antibody detection through ELISA by using third generation ELISA Kit. The Anti-HCV positive serum samples were stored for RT-PCR to estimate the viral load and genotypes of HCV for study. Injecting drug users selected from in and around Lahore Metropolitan from July 2012 to August 2013 was included. The data analysis was completed by using SPSS version 16. A p-value of < 0.05 was considered to be significant.

RESULTS

A total of 241 Injecting drug users were enrolled and screened for Anti HCV in the study. Prevalence of HCV infection in IDUs from Lahore was found to be 36.09%. Education (p=0.000), low socioeconomic status (p=0.011), Blood transfusion (0.003), any tattoo on the body (p=0.002), use of injectable drugs with reused syringes (p=0.000) and sharing of syringes (p=0.001) in groups was significantly associated with HCV infection. Some utensils were also significantly associated with HCV status. The most common subtype of HCV genotype was 3a (n=65) followed by 2a (n=15) and 1a (n=6).

CONCLUSION

The study reveals that IDUs with reused syringes status and sharing of syringes in group had more chances to get HCV infection. The viral load in IDUs infected with different subtypes of genotype was significantly associated.

Substance use and hepatitis C: an ecological momentary assessment study

OBJECTIVE

The objective of this study was to assess craving and mood related to opioid and cocaine use among asymptomatic hepatitis C virus (HCV)+ and HCV- methadone patients who have not started antiviral treatment.

METHODS

In this 28-week prospective ecological momentary assessment (EMA) study, 114 methadone-maintained, heroin- and cocaine-abusing individuals reported from the field in real time on their mood, craving, exposure to drug-use triggers, and drug use via handheld computers.

RESULTS

Sixty-one percent were HCV+; none were overtly symptomatic or receiving HCV treatment. HCV status was not associated with age, sex, race, or past-30-day or lifetime heroin or cocaine use. In event-contingent EMA entries, HCV+ individuals more often attributed use to having been bored, worried, or sad; feeling uncomfortable; or others being critical of them compared with HCV- participants. In randomly prompted EMA entries, HCV+ participants reported significantly more exposure to drug-use triggers, including handling ≥$10, seeing cocaine or heroin, seeing someone being offered/use cocaine or heroin, being tempted to use cocaine, and wanting to see what would happen if they used just a little cocaine or heroin.

CONCLUSIONS

HCV+ individuals experienced more negative moods and more often cited these negative moods as causes for drug use. HCV+ individuals reported greater exposure to environmental drug-use triggers, but they did not more frequently cite these as causes for drug use. The EMA data reported here suggest that HCV+ intravenous drug users may experience more labile mood and more reactivity to mood than HCV- intravenous drug users. The reason for the difference is not clear, but HCV status may be relevant to tailoring of treatment.

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

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

Substance Use Related Stigma: What we Know and the Way Forward

AIMS

To conduct a systematic review of the literature investigating the relationship between stigma experienced by individuals who use drugs.

METHODS

We conducted an online literature search and identified articles related to stigma among individuals who use drugs. Studies evaluating associations between stigma and socio-demographic variables and if applicable clinical and substance use variables are presented. In addition, recommendations for future research are provided.

RESULTS

We identified 26 articles describing 28 studies evaluating stigma. The majorities of studies were published in the last 11 years and conducted in the U.S. Samples were relatively diverse: 41.7% of all participants who provided data identified as racial/ethnic minorities. The vast majority of the relationships between stigma and socio-demographic characteristics were included in only one or very few studies, which limits conclusions. The relationship between stigma and psychological well-being is the only consistent finding reported in the literature. Specifically, results suggest that stigma has a detrimental effect on psychological well-being among individuals who use drugs.

CONCLUSIONS

While this literature is expanding at a rapid pace, this review indicates several areas for future research and needed improvements in research methodology in this area. Specifically, lack of comprehensive description of sample characteristics, lack of construct identification and proper definition, a dearth of longitudinal studies and limited research describing relationships between stigma and substance use behavior are a few areas identified for further research.

Determinants of the underreporting of alcohol consumption by HIV/HCV co-infected patients during face-to-face medical interviews: the role of the physician

OBJECTIVES

The objective of this study was to assess to what extent HIV/HCV co-infected patients underreport alcohol use to their physician with respect to self-reports from self-administered questionnaires (SAQ) and identify correlates of alcohol underreporting during face-to-face medical interviews (FMI).

DESIGN

ANRS-CO13-HEPAVIH is a French multi-center cohort of HIV/HCV co-infected patients.

METHODS

Data were collected at enrolment using both SAQ and FMI while clinical data were retrieved from medical records. Alcohol consumption was assessed through SAQ and compared with FMI patient reports. Correlates of underreporting alcohol consumption during FMI with respect to SAQ were identified using logistic regression analysis.

RESULTS

Among 544 patients, 37% were classified as alcohol abusers according to AUDIT-C in the SAQ. During FMI, 14% underreported alcohol consumption. The following correlates were independently associated with underreporting alcohol consumption in FMI: not receiving HIV treatment, being followed up by a hepatologist for HCV infection and reporting a history of injecting drug use.

CONCLUSIONS

These results highlight the difficulties in alcohol consumption assessment which HCV specialists may face when suggesting to their HIV/HCV co-infected patients that they cease drinking completely. Patient awareness about the real need to reduce their alcohol use before starting HCV therapy may also contribute to underreporting. Innovative strategies for alcohol risk-reduction, including the promotion of controlled consumption and access to multidisciplinary teams, should be implemented for HIV/HCV co-infected patients in order to reduce barriers to HCV treatment.

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

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

Notions of Injecting Drug Users' Candidacy for Hepatitis C Treatment: Conflicting Provider, Patient, and Public Health Perspectives

Uptake of hepatitis C treatment by injecting drug users (IDUs) remains low and little is known about factors influencing treatment uptake by ethnic minority groups. The influence of notions of “candidacy” on “accomplishing” access to antiviral treatment are explored using data from an ethnographic study. Fieldwork and in-depth interviews were conducted with 72 Indo-Chinese IDUs. Cultural contexts, everyday realities of drug use and marginalization, and disengagement from the health system produced notions of candidacy in participants' local worlds. Among the minority assessed for treatment, adjudications of candidacy were perceived to be influenced by power dynamics. Demonstrating abstinence from drug use was understood to be central to establishing legitimate claims for candidacy, suggesting conflicting provider, patient, and public health perspectives. Further research is needed to identify drivers of institutional notions of candidacy and determine ways to ensure these do not produce discriminatory practices and policies that exclude and disadvantage particular groups.

Equitable access to HCV care in HIV-HCV co-infection can be achieved despite barriers to health care provision

Language barrier, race, immigration status, mental health illness, substance abuse and socioeconomic status are often not considered when evaluating hepatitis C virus (HCV) sustained virological response (SVR) in human immunodeficiency virus (HIV) infection. The influence of these factors on HCV work-up, treatment initiation and SVR were assessed in an HIV–HCV coinfected population and compared to patients with HCV mono-infection. The setting was a publicly funded, urban-based, multidisciplinary viral hepatitis clinic. A clinical database was utilized to identify HIV and HCV consults between June 2000 and June 2007. Measures of access to HCV care (ie, liver biopsy and HCV antiviral initiation) and SVR as a function of the above variables were evaluated and compared between patients with HIV–HCV and HCV. HIV–HCV co-infected (n = 106) and HCV mono-infected (n = 802) patients were evaluated. HIV–HCV patients were more often white (94% versus 84%) and male (87% versus 69%). Bridging fibrosis or cirrhosis on biopsy was more frequent in HIV–HCV (37% versus 22%; P = 0.03). HIV infection itself did not influence access to biopsy (50% versus 52%) or treatment initiation (39% versus 38%). Race, language barrier, immigration status, injection drug history and socioeconomic status did not influence access to biopsy or treatment. SVR was 54% in HCV and 30% in HIV–HCV (P = 0.003). Genotype and HIV were the only evaluated variables to predict SVR. Within the context of a socialized, multidisciplinary clinic, HIV–HCV co-infected patients received similar access to HCV work-up and care as HCV mono-infected patients. SVR is diminished in HIV–HCV co-infection independent of language barrier, race, immigration status, or socioeconomic status.

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

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

Effects of heroin-assisted treatment on alcohol consumption: findings of the German randomized controlled trial

Alcohol has been suggested to be a risk factor for opioid-dependent patients in methadone maintenance treatment (MMT). Literature shows that MMT has limited effects on alcohol use. Nevertheless, a decrease in alcohol use was detected in the Swiss heroin-assisted treatment (HAT) study. In this article, we carry out an in-depth analysis of the German HAT trial with the aim of determining whether alcohol use was affected among patients undergoing HAT and MMT. Analysis was carried out using self-reported data on consumption units of alcohol used (CU), Addiction Severity Index composite scores (ASI CSs), and carbohydrate-deficient transferrin (CDT) measures. Results suggest significant reduction of CU and CDT in both groups, yet larger effects in the HAT group. ASI CS significantly decreased in the HAT but not in the MMT group. The greater benefit of HAT in reducing alcohol use may be due to the greater daily frequency of dispensing heroin coupled with a requirement of sobriety at each dosing occasion.

[Prevention of hepatitis C virus infection in drug users]

The high prevalence and incidence rates of the hepatitis C virus (HCV) infections in drug users demonstrate the urgent necessity for a coordinated national prevention strategy. In the shadow of HIV/AIDS the necessary attention to the rapid spreading of the hepatitis C in drug users was started late, without being able to reach the public attention level of HIV/AIDS. The present efforts in the primary and secondary prevention of the hepatitis C in drug users are obviously not sufficient to reduce the prevalence with long-lasting results. Substitution treatment is of central relevance in the prevention of hepatitis C in opiate-dependent subjects, but requires, as current data of the HCV incidence of substituted opiate dependents illustrate, a stronger HCV-specific accentuation. Further settings, which are relevant for the group of intravenous drug users, have to be accessed and sensitized. Furthermore structural and political efforts are necessary, in order to develop a systematic and evidence-based answer to the challenge of the HCV spreading in drug users, in particular due to the fact that a German HCV strategy is still lacking.

Recruitment and follow-up of injecting drug users in the setting of early hepatitis C treatment: insights from the ATAHC study

Despite current injecting drug users (IDUs) being the major risk group for new hepatitis C virus (HCV) infections in most countries, they constitute a small minority of study populations in almost all studies of acute HCV infection treatment. The Australian Trial in Acute Hepatitis C (ATAHC) is examining natural history and treatment efficacy among predominantly IDU-acquired acute HCV. Recruitment is through an Australian network of primary and tertiary care sites. Eligible participants are offered treatment with pegylated-interferon alpha-2a (PEG-IFN) for 24 weeks, with both treated and untreated participants followed for up to three years. Quantitative and qualitative data on injecting behaviour is collected on study participants. Participants are regularly reviewed by a multidisciplinary team that includes the treating clinician, HCV clinic nurse, outreach worker and when necessary are referred to a drug and alcohol worker, social worker, psychiatrist or other appropriate services. A contact log records all interactions between participants and the study team. In September 2006, 121 subjects had been screened, 107 were enrolled and 75 had chosen to commence a 24-week course of PEG-IFN (HIV/HCV coinfected participants are treated with PEG-IFN/ribavirin combination therapy). Eighty per cent of ATAHC participants reported IDU within the previous six months. Recruitment is planned to continue through mid-2007. Through a series of case reports, this paper describes factors that are potential barriers to recruitment, follow-up, and treatment of IDUs in the context of acute HCV infection. PEG-IFN adherence and toxicity, current substance use or mental health issues are not presenting as the only barriers to HCV treatment. Financial and transport difficulties, isolation and social support, and legal issues have been prominent and had the potential to impact on clinic attendance and treatment success. Our work suggests that by using a multidisciplinary approach, potential barriers to recruitment and follow-up of current IDUs to HCV treatment can be effectively addressed, and this highly marginalised population can be successfully engaged and treated.