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Baas L, Meijer K, Bredenoord AL, van der Graaf R. What is a cure through gene therapy? An analysis and evaluation of the use of "cure". MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024:10.1007/s11019-024-10223-w. [PMID: 39172342 DOI: 10.1007/s11019-024-10223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 08/23/2024]
Abstract
The development of gene therapy has always come with the expectation that it will offer a cure for various disorders, of which hemophilia is a paradigm example. However, although the term is used regularly, it is unclear what exactly is meant with "cure". Therefore, the aim of this paper is to analyse how the concept of cure is used in practice and evaluate which of the interpretations is most suitable in discussions surrounding gene therapy. We analysed how cure is used in four different medical fields where the concept raises discussion. We show that cure can be used in three different ways: cure as normalization of the body, cure as obtaining a normal life, or cure as a change in identity. We argue that since cure is a practical term, its interpretation should be context-specific and the various uses can exist simultaneously, as long as their use is suitable to the function the notion of cure plays in each of the settings. We end by highlighting three different settings in the domain of hemophilia gene therapy in which the term cure is used and explore the function(s) it serves in each setting. We conclude that in the clinical application of gene therapy, it could be better to abandon the term cure, whereas more modest and specified definitions of cure are required in the context of health resource allocation decisions and decisions on research funding.
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Affiliation(s)
- Lieke Baas
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Rieke van der Graaf
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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2
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Moore D, Fraser S, Farrugia A, Fomiatti R, Edwards M, Birbilis E, Treloar C. Countering 'the moral science of biopolitics': Understanding hepatitis C treatment 'non-compliance' in the antiviral era. SOCIOLOGY OF HEALTH & ILLNESS 2024; 46:399-417. [PMID: 37740675 DOI: 10.1111/1467-9566.13712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/17/2023] [Indexed: 09/25/2023]
Abstract
Although new hepatitis C treatments are a vast improvement on older, interferon-based regimens, there are those who have not taken up treatment, as well as those who have begun but not completed treatment. In this article, we analyse 50 interviews conducted for an Australian research project on treatment uptake. We draw on Berlant's (2007, Critical Inquiry, 33) work on 'slow death' to analyse so-called 'non-compliant' cases, that is, those who begin but do not complete treatment or who do not take antiviral treatment as directed. Approached from a biomedical perspective, such activity does not align with the neoliberal values of progress, self-improvement and rational accumulation that pervade health discourses. However, we argue that it is more illuminating to understand them as cases in which sovereignty and agency are neither simplistically individualised nor denied, and where 'modes of incoherence, distractedness, and habituation' are understood to co-exist alongside 'deliberate and deliberative activity […] in the reproduction of predictable life' (Berlant, 2007, p. 754). The analysed accounts highlight multiple direct and indirect forces of attrition and powerfully demonstrate the socially produced character of agency, a capacity that takes shape through the constraining and exhausting dynamics of life in conditions of significant disadvantage.
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Affiliation(s)
- David Moore
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia
- School of Humanities and Social Sciences, Deakin University, Burwood, Victoria, Australia
| | - Michael Edwards
- Faculty of Addiction Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Melbourne, Victoria, Australia
| | | | - Carla Treloar
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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3
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Rance J, Grebely J, Treloar C. The time of cure: hepatitis C treatment and the matter of reinfection among people who inject drugs. HEALTH SOCIOLOGY REVIEW : THE JOURNAL OF THE HEALTH SECTION OF THE AUSTRALIAN SOCIOLOGICAL ASSOCIATION 2024; 33:104-118. [PMID: 38373415 DOI: 10.1080/14461242.2024.2315031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
Australia has made considerable progress towards the public-health 'elimination' of the hepatitis C virus. Nonetheless, reinfection remains a key challenge, with little understanding regarding the lived complexities of post-cure life among people who inject drugs. Our analysis examines reinfection through the lens of 'time', a largely overlooked and under-utilised analytical concept within the field of hepatitis C. Drawing on qualitative data from a study examining treatment outcomes and reinfection, our analysis concentrates on three participant accounts or 'cases'. Working within a new materialist framework, we combine recent social science scholarship which, firstly, posits cure as a socio-material 'gathering', and secondly, proposes a 'futurology' of hepatitis C and its treatment. We found participant accounts troubled the neat binary of pre- and post-treatment life, instead detailing the challenges of remaining virologically safe while navigating complex, local life-worlds. Rather than a singular, post-treatment future instantiated by cure, participants described the fluid, emergent nature of what we might describe as 'lived' or 'embodied' time, including multiplicities of becoming in a perpetual present. We conclude that our understanding of reinfection needs to move beyond its current, narrow biomedical conception and organising temporal logic to honour and incorporate complexity in practice.
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Affiliation(s)
- J Rance
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - J Grebely
- The Kirby Institute, UNSW, Sydney, Australia
| | - C Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia
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4
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Kagan D, Seear K, Lenton E, Farrugia A, Valentine K, Mulcahy S. 'I'm not hep C free': afterlives of hepatitis C in the era of cure. MEDICAL HUMANITIES 2023; 49:678-687. [PMID: 37451865 DOI: 10.1136/medhum-2023-012653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
Since the advent of more effective, new-generation treatment for hepatitis C, immense resources have been devoted to delivering cure to as many people with the virus as possible. The scale-up of treatment aims to prevent liver disease, liver cancer and onward transmission of hepatitis C, but social research shows that people also approach treatment with its social promises in mind, including the hope that it might reduce or eradicate stigma from their lives. Such hopes reflect broader ideas about medical cure, which is seen as an end point to illness and its effects, and capable of restoring the self to a (previous) state of health and well-being. But what does cure mean among people for whom treatment does not produce an end to the social effects of a heavily stigmatised disease? While new treatments promise to eliminate hepatitis C, accounts of post-cure life suggest that hepatitis C can linger in various ways. This article draws on interviews with people who have undergone treatment with direct-acting antivirals (n=30) in Australia to explore the meanings they attach to cure and their experiences of post-cure life. We argue that dominant biomedical understandings of cure as an 'ending' and a 'restoration' can foreclose insight into the social and other effects of illness that linger after medical cure, and how individuals grapple with those afterlives. Drawing on recent conceptual re-framings of cure from medical anthropology and disability studies, we suggest that thinking at the limits of 'curative reason' helps to better address the afterlives of chronic illness. In the case of hepatitis C, reconceptualising cure could inform improved and less stigmatising ways of addressing people's post-cure needs. And in the era of hepatitis C elimination, such reconceptualisation is increasingly important as the cohort of people undergoing treatment and cure expands worldwide.
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Affiliation(s)
- Dion Kagan
- Australian Research Centre for Sex, Health and Society, La Trobe University, Bundoora, Victoria, Australia
| | - Kate Seear
- Australian Research Centre for Sex, Health and Society, La Trobe University, Bundoora, Victoria, Australia
| | - Emily Lenton
- Australian Research Centre for Sex, Health and Society, La Trobe University, Bundoora, Victoria, Australia
| | - Adrian Farrugia
- Australian Research Centre for Sex, Health and Society, La Trobe University, Bundoora, Victoria, Australia
| | - Kylie Valentine
- Centre for Social Policy Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Sean Mulcahy
- Australian Research Centre for Sex, Health and Society, La Trobe University, Bundoora, Victoria, Australia
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5
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Nourse G, Farrugia A, Fraser S, Moore D, Treloar C. Optimism and eternal vigilance: Gathering disease, responsible subjects and the hope of elimination in the new hepatitis C treatment era. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104142. [PMID: 37591009 DOI: 10.1016/j.drugpo.2023.104142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/19/2023]
Abstract
The advent of direct-acting antiviral hepatitis C medications has reshaped experiences of hepatitis C treatment and cure. Positioned as a treatment revolution, the new medications mean a world without hepatitis C has become imaginable, and this optimism is reflected in Australia's commitment to the WHO's target of 'eliminating' the virus as a public health threat by 2030. Alongside optimism about new treatments, Australia's current National Hepatitis C Strategy also emphasises the importance of partnerships with, and the 'meaningful involvement' of, priority populations for elimination to be achieved. We draw on Fraser and Seear's (2011) work on hepatitis C as a 'gathering' to examine these developments, and to approach hepatitis C as a disease in-the-making. Analysing 50 interviews conducted with people affected by the virus, we identify three key articulations that combine to trouble the distinction between old and new treatments: (1) the new treatment constitutes the disease as readily curable; (2) nevertheless, those who have been cured are responsibilised against acquiring it again by managing and monitoring their conduct; and (3) in the process, hepatitis C becomes re-constituted as an ongoing threat requiring continual post-cure medical and other monitoring. We argue that while treatment experiences have dramatically improved, responsibilising people affected by hepatitis C to attain cure in the context of an elimination agenda constitutes cure as valuable as much for the greater good as for self-care. This raises pressing ethical and political questions. Overall, we shed light on how, even in a context shaped by the availability of highly effective treatment, the hepatitis C-free body is never hepatitis C-free, but must be continually reproduced through regulatory practices.
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Affiliation(s)
- Gemma Nourse
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia.
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia; Centre for Social Research in Health, University of New South Wales, Australia
| | - David Moore
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Australia
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Seear K, Mulcahy S, Kagan D, Lenton E, Fraser S, Valentine K, Farrugia A. Complicating cure: How Australian criminal law shapes imagined post-hepatitis C futures. SOCIOLOGY OF HEALTH & ILLNESS 2023; 45:179-195. [PMID: 36254737 PMCID: PMC10092810 DOI: 10.1111/1467-9566.13562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
In recent years, highly tolerable and effective drugs have emerged promising a radical new 'post-hepatitis C' world. Optimism about medical cure potentially overlooks discrimination and stigma associated with hepatitis C and injecting drug use. Legal frameworks are especially relevant to hepatitis futures, since the law has the potential to reinforce or alleviate stigma and discrimination. This article explores how hepatitis C figures in Australian criminal law and with what potential effects. Drawing on Bruno Latour's work on legal veridiction, Alison Kafer's work on futurity and disability and case law data collected for a major study on hepatitis C and post-cure lives, we explore how the criminal law handles hepatitis C in the age of cure. We find that law complicates cure, constituting hepatitis C as disabling despite the advent of effective cures. The law steadfastly maintains its own approach to disease, disability and illness, untouched by medical and scientific developments, in ways that might complicate straightforwardly linear imaginaries of cure, transformation and progress of the kind that dominate biomedicine. We explore the implications of these tensions between law and medicine.
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Affiliation(s)
- Kate Seear
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Sean Mulcahy
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Dion Kagan
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Emily Lenton
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Kylie Valentine
- Social Policy Research CentreUniversity of New South WalesSydneyNew South WalesAustralia
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
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7
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Goutzamanis S, Doyle JS, Horyniak D, Higgs P, Hellard M. "Like a pickle that's been unpickled": Emotional, identity and behavioural transformations throughout hepatitis C treatment. PLoS One 2022; 17:e0272401. [PMID: 36508406 PMCID: PMC9744280 DOI: 10.1371/journal.pone.0272401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 07/19/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Stelliana Goutzamanis
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joseph S Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Danielle Horyniak
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Behaviour and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
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8
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Nascimento YDA, Silva LD, Ramalho de Oliveira D. The Lived Experience of Patients Utilizing Second-Generation Direct-Acting Antiviral for Treatment of Chronic Hepatitis C Virus Infection: A Phenomenological Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12540. [PMID: 36231842 PMCID: PMC9566709 DOI: 10.3390/ijerph191912540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
Hepatitis C is a global public health problem, and the aim of this study was to understand the experiences of patients with hepatitis C using second-generation antivirals. In-depth interviews were conducted with ten outpatients, cognitively capable of reporting their experience, followed up at a university clinic. Field diaries kept during the interviews were also used. The researchers carried out a thematic analysis to identify the ways in which individuals experienced their medication; then, these ways were reorganized to encompass the essential structures of the experience. The patients experienced the use of DAAs as providing resolution and it was permeated by: the experience of time-stagnant time, waiting for medication and the cure; the experience of spaces, understood as necessary and imposed spaces; the experience of relationships with others, personified by the support provided by healthcare professionals; the experience of sexuality, when patients developed several coping strategies to deal with the challenges imposed by the treatment. To conclude, increasing the knowledge about the patients' experiences can contribute to improve the healthcare model for hepatitis C, since several patients have severe hepatic impairment, and the eradication of the virus is only one of the stages of patients' treatments.
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Affiliation(s)
- Yone de Almeida Nascimento
- College of Pharmacy, Center for Pharmaceutical Care Studies, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil
| | - Luciana Diniz Silva
- College of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil
| | - Djenane Ramalho de Oliveira
- College of Pharmacy, Center for Pharmaceutical Care Studies, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil
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Fraser S, Moore D, Farrugia A, Fomiatti R, Edwards M, Birbilis E, Treloar C. Exhausted practical sovereignty and lateral agency: Non-uptake of treatment for hepatitis C in the antiviral era. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 107:103771. [PMID: 35952605 DOI: 10.1016/j.drugpo.2022.103771] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022]
Abstract
With the advent of highly effective antiviral treatment for hepatitis C, many people have undergone treatment and been cured. Others, however, have not undergone treatment, even where it is free and readily available. Australia's aim of eliminating the disease by 2030 means this group is of concern to researchers, health professionals and policymakers. This article draws on 50 interviews conducted for a research project on treatment experiences to examine treatment non-uptake in Australia. Informed by Berlant's (2007) work on 'slow death', it analyses experiences of non-uptake to explain the dynamics at work in such outcomes. The analysis is divided into three parts. First, participant Cal describes a lifetime in which hepatitis C, homelessness and prison have shaped his outlook and opportunities. Second, Evan describes intergenerational drug consumption, family contact with the prison system and an equally long history with hepatitis C. Finally, Rose also describes a long history of hepatitis C, complex struggles to improve life and contact with the prison system. All three accounts illuminate the dynamics shaping treatment decisions, calling to mind Berlant's slow death as a process of being 'worn out by the activity of reproducing life' under conditions that both demand self-management, and work against it. In concluding, the article points to Berlant's distinction between 'epidemics' and 'endemics', arguing that its politics apply directly to hepatitis C. In doing so, it highlights the need to address the criminalising, pathologising, capitalist context of 'attrition' (Berlant) that wears out lives even as it fetishises autonomy, responsibility and choice.
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Affiliation(s)
- Suzanne Fraser
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia; Centre for Social Research in Health and Social Policy Research Centre, University of New South Wales.
| | - David Moore
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia; School of Humanities and Social Sciences, Deakin University, Australia
| | - Michael Edwards
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | | | - Carla Treloar
- Australian Research Centre in Sex, Health and Society, La Trobe University, Australia; Centre for Social Research in Health and Social Policy Research Centre, University of New South Wales
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10
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Donaldson SR, Radley A, Dillon JF. 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. Subst Abuse Treat Prev Policy 2022; 17:45. [PMID: 35676732 PMCID: PMC9178822 DOI: 10.1186/s13011-022-00475-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Sarah R Donaldson
- School of Medicine, University of Dundee, Dundee, DD1 9SY, UK.
- NHS Tayside, Dundee, DD1 9SY, UK.
| | - Andrew Radley
- School of Medicine, University of Dundee, Dundee, DD1 9SY, UK
- NHS Tayside, Dundee, DD1 9SY, UK
| | - John F Dillon
- School of Medicine, University of Dundee, Dundee, DD1 9SY, UK
- NHS Tayside, Dundee, DD1 9SY, UK
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11
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Farrugia A, Fomiatti R, Fraser S, Moore D, Edwards M, Birbilis E, Treloar C. Hepatitis C cure as a 'gathering': Attending to the social and material relations of hepatitis C treatment. SOCIOLOGY OF HEALTH & ILLNESS 2022; 44:830-847. [PMID: 35365924 PMCID: PMC9325418 DOI: 10.1111/1467-9566.13467] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/22/2022] [Accepted: 03/14/2022] [Indexed: 05/05/2023]
Abstract
Since the advent of direct-acting antiviral hepatitis C treatments, widespread enthusiasm about disease elimination has emerged. This article examines experiences of hepatitis C treatment and cure in this period. Mobilising Fraser and Seear's (Making disease, making citizens: The politics of hepatitis C, Ashgate, 2011) approach to hepatitis C as a 'gathering', we analyse cure not as a biomedical phenomenon but as a social and material event. To do so, we take a Science and Technology Studies-inspired approach to analyse three complementary cases drawn from an Australian project on experiences of hepatitis C, treatment and cure. First, we analyse the ways a friendship between two women combines with adjustments to treatment access to produce a gathering that makes cure possible. Second, we analyse the forces that gather and distribute responsibility when a cure does not occur in a context shaped by oversimplified treatment logics. Third, we analyse a gathering of relations in which hepatitis C lingers, thereby limiting the cure's possible transformative effects. We argue that, even in an era defined by highly effective medicines, the hepatitis C cure is not necessarily straightforward, but an unpredictable gathering constituted by a fragile coalescing of social and material forces.
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Affiliation(s)
- Adrian Farrugia
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
- National Drug Research InstituteCurtin UniversityPerthWestern AustraliaAustralia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Suzanne Fraser
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
- Centre for Social Research in HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - David Moore
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
| | - Michael Edwards
- National Drug and Alcohol Research CentreUniversity of New South WalesSydneyNew South WalesAustralia
| | - Elizabeth Birbilis
- Prevention and Population and Health BranchPublic Health DivisionDepartment of HealthVictoria State GovernmentMelbourneVictoriaAustralia
| | - Carla Treloar
- Australian Research Centre in Sex, Health and SocietyLa Trobe UniversityMelbourneVictoriaAustralia
- Centre for Social Research in HealthSocial Policy Research CentreUniversity of New South WalesSydneyNew South WalesAustralia
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12
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Beller J, Schäfers J, Haier J, Geyer S, Epping J. Trust in Healthcare during COVID-19 in Europe: vulnerable groups trust the least. ZEITSCHRIFT FUR GESUNDHEITSWISSENSCHAFTEN = JOURNAL OF PUBLIC HEALTH 2022; 31:1-10. [PMID: 35345647 PMCID: PMC8944407 DOI: 10.1007/s10389-022-01705-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/06/2022] [Indexed: 12/30/2022]
Abstract
Aim We examined predictors of trust in the healthcare system during the COVID-19 pandemic in 27 European countries. Subjects and methods We used population-based data drawn from the Living, working and COVID-19 survey (N = 21,884, 52% female, ages 18 to 92 years) covering 27 European countries dated June and July 2020. Multilevel linear regression, linear regression, and regression-tree analyses were conducted. Results We found that most participants tended to trust the healthcare system, although a substantial part could still be classified as distrusting (approx. 21%). Multiple variables, including being middle-aged or of older age, being female, lower levels of education, unemployment, worse general health status, having income difficulties, having unmet needs for healthcare, no healthcare contact during the COVID-19 pandemic, higher mental distress, and loneliness, were significantly associated with lower levels of trust. Among these variables mental distress, income difficulties, and unmet needs for healthcare emerged as especially important and, across European regions and countries, consistent predictors for lower trust in the healthcare system during the COVID-19 pandemic. Conclusions Medically vulnerable subgroups, such as individuals with unmet healthcare needs, higher levels of mental distress, and older age, as well as people living in socially and economically vulnerable situations, such as higher levels of loneliness and financial difficulties, were the least trusting of the healthcare system during the COVID-19 pandemic. As these vulnerable subgroups are also at highest risk for contracting COVID-19 and experiencing negative COVID-19-related outcomes, more targeted prevention and intervention efforts should be implemented in these groups. Supplementary Information The online version contains supplementary material available at 10.1007/s10389-022-01705-3.
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Affiliation(s)
- Johannes Beller
- Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jürgen Schäfers
- Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jörg Haier
- Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Siegfried Geyer
- Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Jelena Epping
- Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Beyond a ‘post-cure’ world: Sketches for a new futurology of hepatitis C. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103042. [DOI: 10.1016/j.drugpo.2020.103042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
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14
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Pourmarzi D, Smirnov A, Hall L, FitzGerald G, Rahman T. 'I'm over the moon!': patient-perceived outcomes of hepatitis C treatment. Aust J Prim Health 2021; 26:319-324. [PMID: 32580867 DOI: 10.1071/py20013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Understanding patient-perceived outcomes is crucial for assessing the effectiveness and acceptability of hepatitis C virus (HCV) treatment. This study aimed to explore patient-perceived outcomes of receiving direct-acting antivirals (DAAs). This study was a part of a mixed-methods case study of the Prince Charles Hospital program for improving access to HCV treatment in community settings. Data were collected using semi-structured interviews with nine patients who were in different stages of their treatment for HCV. The participants were recruited using purposive sampling. All interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Patients emphasised 'having more energy' when reporting improvements in their physical health following treatment. They also reported a newly developed sense of freedom and hope. Improved physical and mental health empowered them to start a healthy lifestyle and to practise self-protection from the risk of re-infection. Patients highlighted their desire to help other patients to receive treatment, which was connected to their experience of the services that they received and their perceived health outcomes. Patients expect and experience various outcomes that are related to the physical, psychological and social aspects of living with, and being cured of HCV. Emphasis on the short-term outcomes of receiving HCV treatment may improve HCV treatment uptake and adherence rates.
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Affiliation(s)
- Davoud Pourmarzi
- School of Public Health and Social Work, Faculty of Health, Institute of Health and Biomedical Innovation (IHBI), Queensland University of Technology, Brisbane, Qld 4059, Australia; and National Centre for Epidemiology and Population Health, Research School of Population Health, College of Health and Medicine, The Australian National University, Canberra, ACT 2601, Australia; and Corresponding author.
| | - Andrew Smirnov
- National Centre for Epidemiology and Population Health, Research School of Population Health, College of Health and Medicine, The Australian National University, Canberra, ACT 2601, Australia
| | - Lisa Hall
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Qld 4006, Australia
| | - Gerard FitzGerald
- School of Public Health and Social Work, Faculty of Health, Institute of Health and Biomedical Innovation (IHBI), Queensland University of Technology, Brisbane, Qld 4059, Australia
| | - Tony Rahman
- Department of Gastroenterology and Hepatology, The Prince Charles Hospital, Brisbane, Qld 4032, Australia
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15
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Goodyear T, Brown H, Browne AJ, Hoong P, Ti L, Knight R. "Stigma is where the harm comes from": Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103238. [PMID: 33902968 DOI: 10.1016/j.drugpo.2021.103238] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/16/2021] [Accepted: 03/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment. METHODS We thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post). RESULTS Our analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts. CONCLUSIONS DAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.
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Affiliation(s)
- Trevor Goodyear
- School of Nursing, University of British Columbia, Vancouver, Canada; British Columbia Centre on Substance Use, Vancouver, Canada
| | - Helen Brown
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Annette J Browne
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Peter Hoong
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada.
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16
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Hendriks S, Pearson SD. Assessing potential cures: are there distinctive elements of value beyond health gain? J Comp Eff Res 2021; 10:255-265. [PMID: 33663230 PMCID: PMC7939098 DOI: 10.2217/cer-2020-0190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/14/2020] [Indexed: 11/21/2022] Open
Abstract
Assessing the 'value' of potential cures can be challenging, as some have suggested that cures may offer distinctive benefits from noncurative treatments. We explore what these - previously unspecified - additional benefits may be. We suggest that three new elements of value seem distinctive to cures: liberation from the identity of being diseased, liberation from the stigma associated with the disease and liberation from the burden of ongoing therapy. However, including additional elements of value in health technology assessment may result in double counting and requires consideration of potential opportunity costs. We suggest health technology assessment should explore the relevance of these three elements of value and may have good reasons to - judiciously - integrate them through the deliberative process.
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Affiliation(s)
- Saskia Hendriks
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD 20814, USA
| | - Steven D Pearson
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD 20814, USA
- Institute for Clinical & Economic Review, Boston, MA 02109, USA
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17
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Rance J, Rhodes T, Lancaster K. Pharmaceutical citizenship in an era of universal access to hepatitis C treatment: Situated potentials and limits. Health (London) 2021; 26:736-752. [PMID: 33506718 DOI: 10.1177/1363459320988887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Until recently, the only medical treatment available for the hepatitis C virus (HCV) was interferon-based therapy, a notoriously long and arduous treatment with limited success. However, in December 2015, the Australian Government announced a scheme of 'universal access' to new, highly effective direct-acting antiviral therapies (DAAs). This article draws on in-depth interviews with community actors engaged in national and state-based drug user and viral hepatitis advocacy to trace how universal access to curative medicines affords revised notions of citizenship and social inclusion among people who inject drugs and others affected by HCV. To inform our analysis, we draw on and combine critical perspectives from the biological citizenship literature, particularly pharmaceutical citizenship, along with work on the concepts of 'publics and counterpublics'. We ask: what kinds of emergent HCV communities or publics are being enacted through our participant accounts in response to the new DAA-era of universal access, and what forms of citizenship and inclusion (or non-citizenship and exclusion) do they postulate? Some accounts indeed enacted treatment as an individual, sometimes collective, 'good': a citizenship potential. However, a number of accounts enacted situated limits to a straightforward actualisation of this potential, performing a model of public health governance that prioritised viral cure whilst rendering injecting drug use and its attendant social disadvantages an absent presence. Reconceptualising HCV treatment within a counterpublic health sensibility would, by engaging with the everyday health needs and aspirations of people living with HCV in conditions of social disadvantage, create space for new social inclusions and citizenships.
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Affiliation(s)
| | - Tim Rhodes
- UNSW Sydney, Australia.,London School of Hygiene and Tropical Medicine, UK
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18
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Van Nuil JI, Shumbusho F, Kateera F, Mukuralinda A, Kabahizi J, Muvunyi CM, Musabeyezu E, Mukabatsinda C, Mbituyumuremi A, Nsanzimana S, Mukerjee J, Gupta N. Care seeking and treatment for hepatitis C infection in Rwanda: A qualitative study of patient experiences. Glob Public Health 2020; 15:1778-1788. [PMID: 32735478 DOI: 10.1080/17441692.2020.1801787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
An estimated 71 million people live with hepatitis C virus (HCV) and without an effective vaccination, control efforts depend entirely on prevention, early diagnosis, and treatment with direct acting antiviral medication. The experiences of accessing care and treatment, as well as how HCV is locally perceived, are context specific and require an understanding of local epidemics. The objectives of this study were to explore the experiences and demand-side barriers for people with chronic HCV infection, as well as describe the social and cultural landscapes in which they experienced, managed, and perceived HCV in Rwanda. Eleven participants provided consent to participate and all completed two semi-structured interviews during treatment within a clinical trial. We identified four themes: (1) diagnosis and use of traditional medicine, (2) access and financial barriers, (3) complex social networks (4) proactivity in care-seeking. Results demonstrate the complex ways in which Rwandans understand HCV, utilise parallel health systems, activate social networks, and the importance of active agency in the opportunities and outcomes for their own health in the context of an early response to a major epidemic. Without recognising communities' understanding and expectations, it is impossible to build a sustainable and successful public health response to HCV.
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Affiliation(s)
| | | | | | | | | | | | - Emmanuel Musabeyezu
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | | | - Joia Mukerjee
- Partners in Health, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Neil Gupta
- Partners in Health, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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19
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Nápoles TM, Batchelder AW, Lin A, Moran L, Johnson MO, Shumway M, Luetkemeyer AF, Peters MG, Eagen KV, Riley ED. 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. J Public Health (Oxf) 2020; 41:e283-e289. [PMID: 31044248 DOI: 10.1093/pubmed/fdz045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Tessa M Nápoles
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF), San Francisco, CA, USA.,Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Abigail W Batchelder
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Ada Lin
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Lissa Moran
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Martha Shumway
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Anne F Luetkemeyer
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Marion G Peters
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, USA
| | - Kellene V Eagen
- San Francisco Department of Public Health, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Elise D Riley
- Department of Medicine, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco (UCSF), San Francisco, CA, USA
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20
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Walker A, Boyce A, Duggal P, Thio CL, Geller G. The Ethics of Precision Rationing: Human Genetics and the Need for Debate on Stratifying Access to Medication. Public Health Genomics 2020; 23:149-154. [PMID: 32516789 PMCID: PMC7508798 DOI: 10.1159/000508141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/23/2020] [Indexed: 12/15/2022] Open
Abstract
Rising prices for new, transformative therapies are challenging health systems around the world, leading many payers and providers to begin rationing access to treatments, even in the countries that have been most resistant to doing so. This is the case for direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV). However, little attention has been paid to the increasing role that human genetics might play in rationing decisions. Researchers have already proposed that genetic markers associated with spontaneous HCV clearance could be used to restrict DAA access for some patients, although treatment would be medically beneficial for those patients. Would such forms of rationing present a form of genetic discrimination? And what of the public health implications of these approaches? Here we present an ethical analysis of such proposals for "precision rationing" and raise 4 key areas of concern. We argue that ethical issues arising in this area are not substantively different from the pressing ethical issues regarding rationing and discrimination more broadly, but provide important impetus for motivating broad public debate to find ethically sound ways of managing genomics and new expensive medications.
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Affiliation(s)
- Alexis Walker
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA,
| | - Angie Boyce
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Chloe L Thio
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA
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21
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Goodyear T, Ti L, Carrieri P, Small W, Knight R. "Everybody living with a chronic disease is entitled to be cured": Challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 81:102766. [PMID: 32416525 DOI: 10.1016/j.drugpo.2020.102766] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent advances in the safety, tolerability, and efficacy of hepatitis C virus (HCV) treatments have led to the introduction of policy changes that include, in some settings, universal coverage of direct-acting antiviral (DAA) treatment for people living with HCV. However, people who inject drugs (PWID), a population with disproportionately high rates of HCV, often experience significant social and structural barriers to care, including when seeking treatment and care for blood-borne viruses. The objective of this study is to identify implementation challenges and opportunities for improving HCV-related care and scaling up DAA treatment for PWID living with HCV in a setting with universal DAA coverage since 2018. METHODS Informed by a critical interpretive framework, this study thematically analyzes data from in-depth, semi-structured interviews conducted between October 2018 and February 2019 with a purposive sample of 15 expert stakeholders (e.g., clinicians, community-based organization representatives, policy makers) related to HCV care or research in British Columbia, Canada. RESULTS Our analysis revealed two key thematics: First, participants described existing challenges for scaling up DAA treatment, including how contextual factors (e.g., housing, stigma) restrict opportunities for PWID to engage in care. Participants also described how strained and compartmentalized health services are onerous to navigate for patients. Second, participants described opportunities for improving HCV-related care through various structural interventions (e.g., improved housing, decriminalization of substance use), and enhanced and more accessible models of care (e.g., decentralized, integrated, outreach-focused, and peer- and nurse-led services). CONCLUSIONS These findings emphasize that several key service delivery and system-level adaptations are required in order to equitably scale up access of DAAs to PWID living with HCV, including policies and programs that are responsive to socio-structural determinants of health.
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Affiliation(s)
- Trevor Goodyear
- British Columbia Centre on Substance Use, Vancouver, Canada; School of Nursing, University of British Columbia, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Patrizia Carrieri
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, Canada; Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada.
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22
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Marshall AD, Grebely J, Dore GJ, Treloar C. Barriers and facilitators to engaging in hepatitis C management and DAA therapy among general practitioners and drug and alcohol specialists-The practitioner experience. Drug Alcohol Depend 2020; 206:107705. [PMID: 31718924 DOI: 10.1016/j.drugalcdep.2019.107705] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since the advent of interferon-free, direct-acting antiviral (DAA) therapies for hepatitis C virus (HCV) infection, prescriber restrictions have been removed worldwide, permitting HCV management outside of hospital-based clinics. To date, there is limited knowledge of the practitioner experience with DAA treatments, particularly among those new to HCV care. The aim of this qualitative study was to investigate barriers and facilitators for HCV management among general practitioners (GPs) who prescribe opioid agonist therapy (OAT) and drug and alcohol specialists. METHODS In-depth, semi-structured telephone interviews were conducted between September 2018 and April 2019. Practitioners from across Australia were purposively sampled and questioned on barriers and facilitators to HCV management in their clinic(s). Data were coded and analysed with iterative categorisation and thematical analysis. RESULTS Thirty practitioners were interviewed. Participants expressed professional fulfillment in managing HCV care and many benefited from specialist mentorship. Most participants expressed frustration with ongoing implementation barriers, notably, a lack of onsite phlebotomy services and liver disease staging equipment. Poor venous access among persons who inject drugs was elucidated as a major barrier to treatment initiation. Some participants did not receive clinic manager support to engage in HCV care. CONCLUSION To achieve HCV targets set by WHO by 2030, practitioners require additional implementation support. As HCV testing remains a barrier to linkage to care, practitioners should be kept well-informed of diagnostic developments. Findings also underscore the importance of initial specialist mentorship with further evidence needed for practitioners based in rural regions.
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Affiliation(s)
- A D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia.
| | - J Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia.
| | - G J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia.
| | - C Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW 2052, Australia.
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Hickman M, Dillon JF, Elliott L, De Angelis D, Vickerman P, Foster G, Donnan P, Eriksen A, Flowers P, Goldberg D, Hollingworth W, Ijaz S, Liddell D, Mandal S, Martin N, Beer LJZ, Drysdale K, Fraser H, Glass R, Graham L, Gunson RN, Hamilton E, Harris H, Harris M, Harris R, Heinsbroek E, Hope V, Horwood J, Inglis SK, Innes H, Lane A, Meadows J, McAuley A, Metcalfe C, Migchelsen S, Murray A, Myring G, Palmateer NE, Presanis A, Radley A, Ramsay M, Samartsidis P, Simmons R, Sinka K, Vojt G, Ward Z, Whiteley D, Yeung A, Hutchinson SJ. Evaluating the population impact of hepatitis C direct acting antiviral treatment as prevention for people who inject drugs (EPIToPe) - a natural experiment (protocol). BMJ Open 2019; 9:e029538. [PMID: 31551376 PMCID: PMC6773339 DOI: 10.1136/bmjopen-2019-029538] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Hepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV 'Treatment as Prevention' (TasP) in PWID. METHODS AND ANALYSIS We plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome - chronic HCV prevalence in PWID - is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a 'virtual cohort' of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes. ETHICS AND DISSEMINATION Extending HCV community care pathways is covered by ethics (ERADICATE C, ISRCTN27564683, Super DOT C Trial clinicaltrials.gov: NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.
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Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - John F Dillon
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Daniela De Angelis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Graham Foster
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
| | - Peter Donnan
- Dundee Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK
| | | | | | - David Goldberg
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | | | - Samreen Ijaz
- National Infection Service, Public Health England, London, UK
| | | | - Sema Mandal
- National Infection Service, Public Health England, London, UK
| | - Natasha Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, UK
| | - Lewis J Z Beer
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee, UK
| | - Kate Drysdale
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Rachel Glass
- National Infection Service, Public Health England, London, UK
| | | | - Rory N Gunson
- West Of Scotland Specialist Virology Centre, NHS Greater Glasgow & Clyde Board, Glasgow, UK
| | | | - Helen Harris
- National Infection Service, Public Health England, London, UK
| | | | - Ross Harris
- National Infection Service, Public Health England, London, UK
| | | | - Vivian Hope
- Liverpool John Moores University, Liverpool, UK
| | - Jeremy Horwood
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Sarah Karen Inglis
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee, UK
| | - Hamish Innes
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Athene Lane
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Jade Meadows
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Andrew McAuley
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Chris Metcalfe
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | | | - Gareth Myring
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | - Norah E Palmateer
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Anne Presanis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Radley
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee, UK
- Directorate of Public Health, NHS Tayside, Dundee, UK
| | - Mary Ramsay
- National Infection Service, Public Health England, London, UK
| | - Pantelis Samartsidis
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ruth Simmons
- National Infection Service, Public Health England, London, UK
| | - Katy Sinka
- National Infection Service, Public Health England, London, UK
| | | | - Zoe Ward
- Population Health Sciences, Bristol Medical School, Bristol, Bristol, UK
| | | | - Alan Yeung
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
| | - Sharon J Hutchinson
- Glasgow Caledonian University, Glasgow, UK
- Health Protection Scotland, Glasgow, UK
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Mattingly TJ, Slejko JF, Perfetto EM, Kottilil S, Mullins CD. What Matters Most for Treatment Decisions in Hepatitis C: Effectiveness, Costs, and Altruism. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:631-638. [DOI: 10.1007/s40271-019-00378-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Elimination of hepatitis C virus infection among people who use drugs: Ensuring equitable access to prevention, treatment, and care for all. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:1-10. [PMID: 31345644 DOI: 10.1016/j.drugpo.2019.07.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 12/12/2022]
Abstract
There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved.
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Madden A, Hopwood M, Neale J, Treloar C. Acceptability of Patient-Reported Outcome and Experience Measures for Hepatitis C Treatment Among People Who Use Drugs. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:259-265. [PMID: 30270403 DOI: 10.1007/s40271-018-0332-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Annie Madden
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Max Hopwood
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | - Joanne Neale
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
- National Addiction Centre, Kings College London, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia.
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Bryant J, Rance J, Hull P, Mao L, Treloar C. Making sense of 'side effects': Counterpublic health in the era of direct-acting antivirals. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:77-83. [PMID: 31221475 DOI: 10.1016/j.drugpo.2019.06.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 01/25/2023]
Abstract
Direct-Acting Antiviral (DAA) treatments for hepatitis C have been widely promoted by health promotion professionals and medical clinicians as being 'side-effect free'. In this paper, we draw on data that troubles this approach. We used a mixed method design to collect data from people who inject drugs, and who were DAA treatment naïve, in New South Wales, Australia. We describe knowledge about and perceptions of DAA treatment. We found that concerns about side effects were commonplace - for example, one-third (37%) of participants who had not taken up treatment worried "a lot" about 'side effects' - and that these concerns were underpinned by a general distrust and suspicion of medical institutions and their technologies, including widespread negative associations linked to interferon treatment. In trying to make sense of this, we draw on the concept of counterpublic health and its recognition that the everyday health needs, knowledges and aspirations of subordinated citizens frequently contradict the normative frameworks governing public health interventions. We suggest that failing to engage with concerns about 'side effects' could hinder elimination efforts. Our analysis suggests that addressing the issue of 'side effects' within the 'public' discourse of DAAs will not dampen or damage elimination efforts, as some might fear, but rather it will legitimate the concerns of people who inject, decrease their suspicion of medical interventions, and better support the uptake of DAA treatments.
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Affiliation(s)
- Joanne Bryant
- Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia.
| | - Jake Rance
- Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia.
| | - Peter Hull
- Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia.
| | - Limin Mao
- Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia.
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, 2052, Australia.
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Høj SB, Jacka B, Minoyan N, Artenie AA, Bruneau J. Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:11-23. [PMID: 31003825 DOI: 10.1016/j.drugpo.2019.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/22/2019] [Accepted: 04/01/2019] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Stine Bordier Høj
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada.
| | - Brendan Jacka
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Nanor Minoyan
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Andreea Adelina Artenie
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; École de Santé Publique de l'Université de Montréal, 7101 Avenue du Parc, Montréal, Québec, H3N 1X9, Canada
| | - Julie Bruneau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Québec, H2X 0A9, Canada; Département de Médicine Familiale et Médecine d'Urgence, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada.
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Life projects: the transformative potential of direct-acting antiviral treatment for hepatitis C among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:138-145. [PMID: 30995968 DOI: 10.1016/j.drugpo.2019.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES People who inject drugs (PWID) are disproportionately affected by chronic hepatitis C (HCV) in high-income countries. The advent of direct-acting antivirals (DAAs) makes treatment of this underserved population more possible than ever. The dearth of programs adapted to the needs of PWID and stigma associated with drug use and chronic HCV pose significant barriers to the effective uptake of treatment among this population. We employed "life projects" as a conceptual framework to examine the social incentives of PWID being treated for HCV. This study advances the existing literature on the transformative potential of HCV treatment among PWID, explores how these transformations may affect treatment success, and discusses implications for decisions around whether and when to treat PWID. METHODS We conducted in-depth interviews with participants of a pilot clinical trial testing the effective delivery of DAA treatment to PWID within two healthcare for the homeless clinic settings - one group receiving opioid agonist therapy (OAT) and another group frequenting a needle and syringe exchange program (NSP). A purposive sample of 27 participants was selected based on place of care. Interviews were transcribed, coded, and analysed for patterns using a priori domains and emergent themes. RESULTS Participants in both treatment groups described significant life projects that motivated them to complete HCV treatment. These projects included social redemption, strengthening of relationships, pursuit of abstinence from substance use, and harm reduction. These themes were consistent between treatment groups, though more participants in the syringe exchange group relied on harm reduction than on pursuing abstinence to prevent reinfection after achieving virologic cure. CONCLUSION Understanding the incentives that propel PWID to complete HCV treatment could help to enhance treatment uptake and adherence through dedicated programs that address current barriers to care.
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Madden A, Hopwood M, Neale J, Treloar C. Beyond cure: patient reported outcomes of hepatitis C treatment among people who inject drugs in Australia. Harm Reduct J 2018; 15:42. [PMID: 30111327 PMCID: PMC6094926 DOI: 10.1186/s12954-018-0248-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Annie Madden
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - Max Hopwood
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - Joanne Neale
- Centre for Social Research in Health, UNSW, Sydney, Australia.,National Addiction Centre, King's College London, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia.
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Harris M, Rhodes T. Caring and curing: Considering the effects of hepatitis C pharmaceuticalisation in relation to non-clinical treatment outcomes. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 60:24-32. [PMID: 30092546 DOI: 10.1016/j.drugpo.2018.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Magdalena Harris
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, United Kingdom.
| | - Tim Rhodes
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, United Kingdom
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Richmond JA, Ellard J, Wallace J, Thorpe R, Higgs P, Hellard M, Thompson A. Achieving a hepatitis C cure: a qualitative exploration of the experiences and meanings of achieving a hepatitis C cure using the direct acting antivirals in Australia. HEPATOLOGY, MEDICINE AND POLICY 2018; 3:8. [PMID: 30288331 PMCID: PMC6091021 DOI: 10.1186/s41124-018-0036-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/27/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Universal access to the hepatitis C direct acting antiviral (DAAs) regimens presents a unique opportunity to eliminate hepatitis C in Australia. Large numbers of Australians have already been cured using these treatments, however, the numbers presenting for treatment have begun to plateau. This study explored how people experienced and understood being cured of hepatitis C, with the aim of informing interventions to increase uptake of DAA treatment among people with hepatitis C. METHODS This qualitative study used semi-structured interviews to explore the experiences of people with hepatitis C taking DAAs accessing both hospital and community clinics. Interviews were conducted 12 weeks after treatment completion. Participants were asked to reflect on their experience of living with hepatitis C, their reasons for seeking treatment, and their experience of, DAA treatments. Participants were also asked to reflect on the meaning of being cured, and how they shared this experience with their peers. Interviews were transcribed verbatim and key themes were identified using inductive thematic analysis. RESULTS Twenty participants were interviewed. While participants described a range of physical health benefits of achieving a hepatitis C cure it was an improved sense of psychological wellbeing that had the most significant impact on participants' lives. The majority described their relief about no longer living with the burden of an uncertain future due to anxiety about developing liver disease or cancer, as well as fear of infecting others. Participants who had a past history of injecting drug use, described being cured as a way to break the connection with their past. Participants who were current injectors raised concerns about re-infection. CONCLUSION Feeling "normal" and not infectious allows people to live with reduced psychological distress, in addition to the physical benefits of no longer being at risk of developing serious liver disease. Future engagement strategies targeting people who are not accessing hepatitis health care need to promote the lived experience of being cured and the substantial psychological, and physical health benefits, offered by achieving a cure. Interventions aimed at people who are currently injecting also need to highlight the availability of re-treatment in conjunction with primary prevention strategies.
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Affiliation(s)
- Jacqueline A. Richmond
- Australian Research Centre in Sex, Health and Society, La Trobe University, Bundoora, Victoria Australia
- Disease Elimination, The Burnet Institute, Prahran, Victoria Australia
- Department of General Practice, The University of Melbourne, Parkville, Victoria Australia
| | - Jeanne Ellard
- Kirby Institute, University of New South Wales, Kensington, New South Wales Australia
| | - Jack Wallace
- Australian Research Centre in Sex, Health and Society, La Trobe University, Bundoora, Victoria Australia
- Disease Elimination, The Burnet Institute, Prahran, Victoria Australia
| | - Rachel Thorpe
- Australian Research Centre in Sex, Health and Society, La Trobe University, Bundoora, Victoria Australia
| | - Peter Higgs
- Disease Elimination, The Burnet Institute, Prahran, Victoria Australia
- Department of Public Health, La Trobe University, Bundoora, Victoria Australia
| | - Margaret Hellard
- Disease Elimination, The Burnet Institute, Prahran, Victoria Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
| | - Alexander Thompson
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC Australia
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Høj SB, Minoyan N, Artenie AA, Grebely J, Bruneau J. The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges? CANADIAN LIVER JOURNAL 2018; 1:4-13. [PMID: 35990720 PMCID: PMC9202798 DOI: 10.3138/canlivj.1.2.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 07/28/2023]
Abstract
Background The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern. Methods This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada. Results A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility. Conclusions Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.
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Affiliation(s)
- Stine Bordier Høj
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Nanor Minoyan
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Andreea Adelina Artenie
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Julie Bruneau
- Research Centre of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, Québec, Canada
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Borgia G, Maraolo AE, Nappa S, Gentile I, Buonomo AR. NS5B polymerase inhibitors in phase II clinical trials for HCV infection. Expert Opin Investig Drugs 2017; 27:243-250. [PMID: 29271672 DOI: 10.1080/13543784.2018.1420780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) infection might be the first chronic viral disease to be eradicated without the introduction of a prophylactic vaccine. This is essentially due to therapeutic revolution encapsulated by the advent of direct-acting antivirals (DAA) agents, whose efficacy, safety and tolerability (all oral regimens) have made the previous standard of care (interferon plus ribavirin) a vestige of the past. The new regimens achieve very high response rates and have an excellent tolerability profile. Notwithstanding, the first wave of DAAs has brought over problems regarding costs and failures which warrant research and development of further antiviral molecules. AREAS COVERED This review outlines the main clinical data concerning novel NS5B polymerase inhibitors currently in pipeline, focusing on the ones that have completed a phase 2 trial. EXPERT OPINION NS5B is one the main viral target for anti-HCV therapy. The large majority of the approved regimens so far include a NS5B inhibitor. Although not frequently, failure related to mutations can occur. The potential place in therapy in the mid-term of new NS5B inhibitors may be, in the first instance, the role of backbone in salvage combinations with DAAs of other classes.
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Affiliation(s)
- Guglielmo Borgia
- a Department of Clinical Medicine and Surgery , University of Naples "Federico II" , Naples , Italy
| | - Alberto Enrico Maraolo
- a Department of Clinical Medicine and Surgery , University of Naples "Federico II" , Naples , Italy
| | - Salvatore Nappa
- a Department of Clinical Medicine and Surgery , University of Naples "Federico II" , Naples , Italy
| | - Ivan Gentile
- a Department of Clinical Medicine and Surgery , University of Naples "Federico II" , Naples , Italy
| | - Antonio Riccardo Buonomo
- a Department of Clinical Medicine and Surgery , University of Naples "Federico II" , Naples , Italy
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Grebely J, Bruneau J, Lazarus JV, Dalgard O, Bruggmann P, Treloar C, Hickman M, Hellard M, Roberts T, Crooks L, Midgard H, Larney S, Degenhardt L, Alho H, Byrne J, Dillon JF, Feld JJ, Foster G, Goldberg D, Lloyd AR, Reimer J, Robaeys G, Torrens M, Wright N, Maremmani I, Norton BL, Litwin AH, Dore GJ. Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:51-60. [PMID: 28683982 PMCID: PMC6049820 DOI: 10.1016/j.drugpo.2017.05.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 04/11/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023]
Abstract
Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.
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Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | - Julie Bruneau
- CHUM Research Centre (CRCHUM), Centre Hospitalier de l'Université de Montréal, Montréal, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Jeffrey V Lazarus
- CHIP, Rigshospitalet, University of Copenhagen, Denmark; Barcelona Institute of Global Health (ISGlobal), Hospital Clínic, Barcelona, Spain
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway; University of Oslo, Oslo, Norway
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Australia
| | | | - Levinia Crooks
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia; Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Sydney, Australia
| | - Håvard Midgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway; Institute for Clinical Medicine, University of Oslo, Norway; Department of Gastroenterology, Oslo University Hospital, Norway
| | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Australia, Sydney, Australia
| | - Hannu Alho
- University of Helsinki, Helsinki, Finland; National Institute for Health and Welfare, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Jude Byrne
- Australian Injecting & Illicit Drug Users League, Canberra, Australia
| | - John F Dillon
- Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
| | - Graham Foster
- The Liver Unit, Queen Mary University of London, London, United Kingdom
| | - David Goldberg
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom; Health Protection Scotland, Glasgow, United Kingdom
| | | | - Jens Reimer
- Centre for Interdisciplinary Addiction Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Geert Robaeys
- Department of Gastroenterology and Hepatology, Ziekenhuis Oost Limburg, Genk, Belgium; Department of Hepatology, UZ Leuven, Leuven, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Marta Torrens
- Institute of Neuropsychiatry & Addictions-Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Icro Maremmani
- Santa Chiara University Hospital, University of Pisa, Italy
| | - Brianna L Norton
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Alain H Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
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Grebely J, Bruneau J, Bruggmann P, Harris M, Hickman M, Rhodes T, Treloar C. Elimination of hepatitis C virus infection among PWID: The beginning of a new era of interferon-free DAA therapy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:26-33. [DOI: 10.1016/j.drugpo.2017.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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