Integrating hepatitis, STD, and HIV services into a drug rehabilitation program

Assessment of facility performance during mass treatment of chronic hepatitis C in Egypt: Enablers and obstacles

BACKGROUND

The national committee for control of viral hepatitis (NCCVH) in Egypt, settled by the Ministry of health, treated over one million patients in around 60 centers with chronological changes in drug combinations. This research aims to study the health care facilities and services provided by NCCVH treatment centers in Egypt and explore hinders faced.

METHODS

A cross-sectional operational research study. Multistage random sampling technique was applied for Egyptian governorates. From each stratum one governorate was chosen from which one center was randomly selected. Quality of recorded data for each center in the central server (Data-oriented parameter), newly designed score to assess the overall performance of the centers was retrieved from computer based recording system. A self-administered questionnaire was completed by the centers head.

RESULTS

This study included 24 treatment centers from urban, rural areas, Upper and Lower Egypt. The Upper centers showed the best completeness of follow-up records and the least compliance rates. None of the centers had 100% completeness of follow-up data. Proportion of SVR is minimally less than proportion of patient with known outcome in all treatment centers. A novel indicator standardizing the comparisons of performance of different facilities was introduced: Total number of physicians/total number of SVR patients with completed records. The highest response rate: Monfiya Governorate (Lower Egypt), Aswan (Upper Egypt), Completeness of follow-up records: Kalyoubia (Lower Egypt), Sohag governorate (Upper Egypt). The average administrative score was 64%.

CONCLUSION

Challenges of NCCVH program: overcrowdings, resistant sociocultural background among rural patients, limited accessibility for internal migrants and incompleteness of data entry are system lacking points. Strengths include, clear patient pathway, well-established database online application, well-trained physicians and treatment availability.

Integrating HIV and substance use services: a systematic review

INTRODUCTION

Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems.

METHODS

Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias.

RESULTS AND DISCUSSION

11,057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from mirco (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services.

CONCLUSIONS

Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.

Hepatitis C Virus Treatment Access Among Human Immunodeficiency Virus and Hepatitis C Virus (HCV)-Coinfected People Who Inject Drugs in Guangzhou, China: Implications for HCV Treatment Expansion

Background. Hepatitis C virus (HCV) treatment access among human immunodeficiency virus (HIV)/HCV-coinfected people who inject drugs is poor, despite a high burden of disease in this population. Understanding barriers and facilitators to HCV treatment uptake is critical to the implementation of new direct-acting antivirals.

Methods. We conducted in-depth interviews with patients, physicians, and social workers at an HIV treatment facility and methadone maintenance treatment centers in Guangzhou, China to identify barriers and facilitators to HCV treatment. We included patients who were in various stages of HCV treatment and those who were not treated. We used standard qualitative methods and organized data into themes.

Results. Interview data from 29 patients, 8 physicians, and 3 social workers were analyzed. Facilitators and barriers were organized according to a modified Consolidated Framework for Implementation Research schematic. Facilitators included patient trust in physicians, hope for a cure, peer networks, and social support. Barriers included ongoing drug use, low HCV disease knowledge, fragmented reimbursement systems, HIV exceptionalism, and stigma.

Conclusions. Expanding existing harm reduction programs, HIV treatment programs, and social services may facilitate scale-up of direct-acting antivirals globally. Improving integration of ancillary social and mental health services within existing HIV care systems may facilitate HCV treatment access.

Enhancing HIV/AIDS, viral hepatitis, sexually transmitted disease, and tuberculosis prevention in the United States through program collaboration and service integration: the case for broader implementation

HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis in the United States remain major public health concerns. The current disease-specific prevention approach oftentimes has led to narrow success and missed opportunities for increasing program capacity, leveraging resources, addressing social and structural determinants, and accelerating health impact-suggesting a need for greater innovation to prevent related diseases. The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's Program Collaboration and Service Integration (PCSI) strategic priority aims to strengthen collaborative engagement across these disease areas and to integrate services at the client level. In this review, we articulate the 5 principles of PCSI-appropriateness, effectiveness, flexibility, accountability, and acceptability. Drawing upon these principles and published literature, we discuss the case for change that underlies PCSI, summarize advances in the field since 2007, and articulate key next steps. Although formal evaluation is needed to fully assess the health impact of PCSI, available evidence suggests that this approach is a promising tool to advance prevention goals.

Reasons for Nonattendance across the Hepatitis C Disease Course

This descriptive qualitative study examined the patient, provider, and institutional factors contributing to nonattendance for hepatitis C (HCV) care throughout the disease course. Eighty-four patients and health and social care providers were interviewed. Thematic analysis of the data yielded 6 interrelated nonattendance themes: self-protection, determining the benefits, competing priorities, knowledge gaps, access to services, and restrictive policies. Factors within the themes varied with the disease course, type of provider/service, and patient context. Nonattendance could span months to years and most frequently began at diagnosis where providers either advised that followup was not necessary or did not recommend any followup. The way services were organized (low barrier access) and delivered (nonjudgmental approach) and higher HCV knowledge levels of patients and providers encouraged attendance. This is the first study to explore the reasons for nonattendance for HCV care throughout the disease course and validate them from multiple perspectives. There are missed opportunities for providers to encourage attendance throughout the disease course beginning at diagnosis. Interventions required include development of integrated health and social service delivery models; mechanisms to improve knowledge dissemination of the disease, its management, and treatment; and implementation of standardized followup protocols for liver disease monitoring in primary care.

Birth cohort screening for chronic hepatitis during colonoscopy appointments

OBJECTIVES

More than 70% of infections with hepatitis C viruses (HCV) occur among people born between 1945 and 1965 (baby boomers). The US Centers for Disease Control estimate that 70% of people with chronic hepatitis are not aware that they are infected with a virus. We performed a prospective trial to determine whether people born during this time period would accept testing for chronic viral infection (hepatitis B virus (HBV) and HCV) during routine colonoscopies. We also evaluated acceptance and efficacy of screening for immunity to hepatitis A (HAV) and B viruses.

METHODS

During a 3-month period, 500 people, 50-65 years old, who received a colonoscopy were offered a test for viral hepatitis. Patients answered questions about vaccination, exposure, diagnoses, and risk factors related to viral hepatitis, and blood samples were collected. Patients who tested positive for antibodies to HCV or hepatitis B surface antigen (HBsAg) were contacted for further testing and possible therapy. Patients without immunity to HAV or HBV were offered vaccinations.

RESULTS

Three hundred and seventy-six people (158 men) agreed to be tested. Four were found to have antibodies against HCV and one had detectable virus. None of the patients tested positive for HBsAg; 136 (36%) had at least one risk factor for chronic hepatitis and 31 (8%) had multiple risk factors. Three hundred and fifteen patients (84%) were not immune to HAV, HBV, or both viruses.

CONCLUSIONS

It is possible to screen patients for viral hepatitis during visits for routine colonoscopy. This approach can identify individuals with undiagnosed chronic HBV and HCV infections who could benefit from education, vaccination, or therapy.

The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women

We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.

Hepatitis vaccination of men who have sex with men at gay pride events

Prevention researchers have advocated primary prevention such as vaccination in alternative venues. However, there have been major questions about both the attendance of, and the ability to, vaccinate high-risk individuals in such settings. The current study seeks to assess the feasibility of vaccinating high-risk men who have sex with men (MSM) at Gay Pride events. The research questions are: Do gay men who are sampled at Gay Pride events engage in more or less risky behavior than gay men sampled at other venues? Do the gay men who receive hepatitis vaccinations at Gay Pride engage in more or less risky behavior than gay men at Gay Pride who do not receive hepatitis vaccination? Of the 3689 MSM that completed the Field Risk Assessment (FRA), 1095/3689 = 29.68% were recruited at either the 2006 or 2007 Long Beach, California Gay Pride events. The remaining, 2594/3689 = 70.32% were recruited at Long Beach gay bars, gay community organizations and institutions, and through street recruitment in various gay enclaves in the Long Beach area. Logistic regression analysis yielded eight factors that were associated with non-attendance of Gay Pride: Age, had sex while high in the last 12 months, had unprotected anal intercourse (UAI) in the last 12 months, had sex for drugs/money in the last 12 months, been diagnosed with a sexually transmitted infection (STI) in the last 12 months, used nitrites (poppers) in the last 12 months, and used methamphetamine in the last 12 months. Identifying as White, Asian, or African American compared to Hispanic was also associated with non-attendance. Bivariate analysis indicated that, of the MSM sampled at Gay Pride, 280/1095 = 25.57% received a hepatitis vaccination there. The MSM sampled at Gay Pride who reported engaging in UAI or having used any stimulant (cocaine, crack-cocaine, or methamphetamine) in the last 12 months were more likely to receive hepatitis vaccination on-site. The results provide evidence for the viability of successfully vaccinating high-risk MSM at Gay Pride events. However, it is vital that no-cost vaccinations are also funded in other community settings such as STI clinics, drug treatment programs, prisons, universities, and other community resource centers in order to reach those additional high-risk MSM who do not attend Gay Pride.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Vaccinating adolescents in high-risk settings: lessons learned from experiences with hepatitis B vaccine

Meeting the health needs of adolescents who live in high-risk settings such as homeless shelters, migrant camps, juvenile detention centers, prisons, and other types of residential facilities presents many challenges. Although there is no doubt that adolescents in many high-risk settings are at increased risk for hepatitis B and human papillomavirus, acute medical and psychological problems may consume all of the provider's time and resources. Potential health threats such as vaccine-preventable diseases must necessarily be given lower priority. Lack of vaccination expertise, supplies, and access to records further complicate delivery of vaccines. Since the 1990s, a number of approaches have been used to deliver hepatitis B vaccine to adolescents in many high-risk settings. Close collaboration among state and federal programs, local health departments, and community-based organizations has been necessary to introduce and sustain the delivery of vaccines to these young people. Medicaid, Statute 317 of the Public Health Service Act, the Vaccines for Children program, and State Children's Health Insurance Program have been used to finance vaccinations for adolescents 18 years or younger, and the expanded Medicaid option in the Foster Care Independence Act of 1999 has been used for adolescents older than 18 years of age. A number of states allow adolescents under age 18 to consent to their own hepatitis B vaccination under laws passed to allow treatment of sexually transmitted infections without parental consent. In this article, we present the experiences of several model programs that developed successful hepatitis B vaccination programs in venues that serve adolescents at risk, the important role of state laws and state agencies in funding immunization and other preventive health services for adolescents in high-risk situations, and discuss barriers and means to resolve them.

Harm reduction, hepatitis C and opioid pharmacotherapy: an opportunity for integrated hepatitis C virus-specific harm reduction

While harm reduction advocates, policy makers and practitioners have a right to be proud of the impact of interventions such as needle and syringe programmes on HIV risk, we can be less sanguine about the ongoing high levels of HCV transmission among injecting drug users (IDUs) and the expanding burden of hepatitis C virus (HCV)-related liver disease. In this Harm Reduction Digest Drs Byrne and Hallinan from the Redfern Clinic and Dr Dore from the National Centre in HIV Epidemiology and Clinical Research offer a model of integrated HCV prevention and treatment services within the setting of opioid pharmacotherapy. In their experience, this common-sense approach provides an opportunity to reduce the burden of HCV and improve overall patient management. They believe that the key elements of a HCV-specific harm reduction model include: regular HCV testing; clinical assessment and determination of need for HCV treatment referral; use of broader HCV treatment inclusion criteria; and flexibility in opioid pharmacotherapy dosing. In an environment when our macro harm reduction interventions seem to have, at best, modest impact on HCV transmission, good clinical practice may be our most effective strategy against the HCV epidemic. This paper provides some practical suggestions as to how this can be done.

Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.

Does integrating viral hepatitis services into a public STD clinic attract injection drug users for care?

OBJECTIVE

Injection drug users (IDUs) are at high risk for multiple health problems, including human immunodeficiency virus (HIV), viral hepatitis, and sexually transmitted diseases (STDs), and are likely to have poor access to health care. To more effectively serve high-risk clients, experts recommend that programs accessed by such client populations offer integrated services. In 2000, the New York City Department of Health and Mental Hygiene integrated viral hepatitis services (vaccine and screening) into a publicly funded STD clinic. We evaluated integrated service delivery to high-risk IDUs at this clinic.

METHODS

Hepatitis data were reviewed to identify clients who self-reported as IDUs. STD medical records of these clients were abstracted to ascertain primary reason for clinic visit, STD/HIV services received, and diagnoses made.

RESULTS

Between May 2000 and March 2004, 8,778 individuals received hepatitis services, of whom 3% (279/8,778) reported injection drug use. Nearly 60% (161/279) of IDUs reported availability of hepatitis services as the primary reason for the clinic visit. Of these 161 clients, 103 (64%) also received other services; 54% (55/103) had an STD exam (yielding 12 new STD diagnoses), and 59% (61/103) had HIV counseling and testing (yielding two new HIV cases). Of these 103 clients, 31 (30%) were referred to the clinic for hepatitis services from a drug treatment center, and 77% (24/31) tested positive for the antibody to hepatitis C virus.

CONCLUSIONS

Integrated hepatitis services appeared to attract IDUs to this STD clinic, where many also benefited from STD/HIV exams, testing, treatment, and referrals they may not have received otherwise.

Partner notification for persons with chronic hepatitis B virus infection: use of a syphilis model service

BACKGROUND

Adults with chronic hepatitis B virus (HBV) infection are usually the source of infection for persons who acquire sexually transmitted HBV infection. Vaccinating sex- and needle-sharing partners is recommended.

GOAL

To evaluate the usefulness of a syphilis model partner notification (PN) service for high-risk persons with chronic HBV infection.

STUDY DESIGN

Locatable partners were offered serologic testing and HBV vaccination.

RESULTS

Of 190 eligible case patients, 129 (68%) were interviewed, which included 47 men who have sex with men (MSM), 26 who reported injecting drug use (IDU), and 12 who were MSM and injected drugs. Among the 129 interviewed, 85 (66%) reported having =1 recent sex partner, 46 (36%) provided locating information for 47 partners, 38 partners accepted PN services, 15 were not immune, and 14 (7% of total eligible case patients) started and 9 completed the HBV vaccine series. Overall, 15% of case patients were also hepatitis C positive, and 29% were HIV infected. PN services cost was estimated at 1472 US dollars per vaccinee.

CONCLUSION

High-risk persons with chronic HBV infection provided few names or locating information for their partners, and the proportion eligible for vaccination was low. An integrated approach that provides hepatitis C screening, human immunodeficiency virus testing, and referral might be more useful and should be evaluated.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.