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Foppiano Palacios C, Dubose B, Schmalzle S. Risk Factors Associated With Unsuccessful Linkage to Outpatient Hepatitis C Care. Cureus 2024; 16:e58313. [PMID: 38752075 PMCID: PMC11095415 DOI: 10.7759/cureus.58313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Modern direct-acting antivirals (DAAs) can treat and cure hepatitis C virus (HCV) infection. Treatment of HCV at a population level has the potential to decrease the prevalence of chronic HCV infection and sequela. Unfortunately, many patients fall off the HCV treatment cascade and do not complete HCV treatment. As social determinants of health (SDHs) affect HCV acquisition, we sought to evaluate factors that may limit successful linkage to outpatient HCV care. Methods We conducted a case-control study by matching patients who missed and those who attended their outpatient HCV visits in 2018. We matched cases in a 1:1 ratio using propensity scores. Results Of 1,539 patients, 161 (10.5%) did not attend their HCV clinic appointment. Factors associated with a missed HCV visit on bivariate testing included identifying as Black (p=0.03), housing instability (p<0.001), transportation difficulty (p<0.001), history of medication non-adherence (p<0.001), and undergoing screening during an inpatient admission (p<0.001). Multivariate testing found transportation difficulty (p<0.001) and inpatient admission (p=0.002) to be associated with missing their HCV appointment. Patients who attended their HCV visit were more likely to be alive by the end of 2018 (p=0.07). Conclusion Patients who missed an initial scheduled infectious disease (ID) clinic appointment for HCV treatment had higher rates of housing instability, transportation difficulties, and medication non-adherence. Patients diagnosed with HCV infection should be provided additional support as appropriate to address the social determinants of health that may limit linkage to outpatient HCV care.
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Affiliation(s)
- Carlo Foppiano Palacios
- Department of Medicine, Cooper University Hospital, Camden, USA
- Departments of Internal Medicine and Pediatrics, University of Maryland Medical Center, Baltimore, USA
| | - Brianna Dubose
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Sarah Schmalzle
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
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Talal AH, George SJ, Talal LA, Dharia A, Ventuneac A, Baciewicz G, Perumalswami PV, Dickerson SS. Engaging people who use drugs in clinical research: integrating facilitated telemedicine for HCV into substance use treatment. RESEARCH INVOLVEMENT AND ENGAGEMENT 2023; 9:63. [PMID: 37533127 PMCID: PMC10399008 DOI: 10.1186/s40900-023-00474-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND People who use drugs (PWUD) have difficulty participating in clinical research. We evaluated approaches to engage PWUD in clinical research, using facilitated telemedicine for hepatitis C virus (HCV) care as an example. METHODS We analyzed stakeholder interview transcripts and study-related data (i.e., progress reports, meeting minutes) from interrelated studies to understand engagement experiences at the patient, site, and organizational levels. Stakeholders include patient-participants, opioid treatment program (OTP) staff and administrators, and research team members involved in HCV management through facilitated telemedicine integrated into OTPs. RESULTS Three themes emerged. Initially, the research team sought understanding of the unique culture and community of each OTP (Theme 1). The team built trusting relationships through education, communication, and feedback (Theme 2). Finally, the research team enhanced collaborative care and incorporated the patients' voice to improve health outcomes (Theme 3). Patient-participants and OTP staff endorsed the integrated HCV care approach. Engagement practices are summarized as the CREATE framework (C = culture, R = respect, E = educate, A = advantage, T = trust, E = endorse). CONCLUSIONS PWUD engagement in clinical research is maximized by building trusting relationships with open communication channels. Understanding the community, demonstrating respect, and augmenting knowledge are foundational for engaging PWUD in clinical research. These practices are transferable to engagement of PWUD in clinical research broadly.
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Affiliation(s)
- Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, State University of New York, 875 Ellicott Street, Suite 6090, Buffalo, NY, 14203, USA.
| | - Saliyah J George
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Arpan Dharia
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, State University of New York, 875 Ellicott Street, Suite 6090, Buffalo, NY, 14203, USA
| | - Ana Ventuneac
- START Treatment and Recovery Centers, Brooklyn, NY, USA
| | | | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suzanne S Dickerson
- Division of Biobehavioral Health and Clinical Sciences, School of Nursing, University at Buffalo, Buffalo, NY, USA
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recommandations pour la prise en charge de l'infection par le virus de l'hépatite C chez les usagers de drogues par injection. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:101669. [PMID: 26847504 DOI: 10.1016/j.drugpo.2015.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | - 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, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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4
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Empfehlungen zur Hepatitis Versorgung bei Drogenkonsumierenden. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:101670. [PMID: 26749563 DOI: 10.1016/j.drugpo.2015.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - 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, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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Primary Care Associated With Follow Up Viral Load Testing in Patients Cured of Hepatitis C Infection With Direct Acting Antivirals at a Multidisciplinary Addiction Treatment Program: Insights From a Real-World Setting. J Addict Med 2022; 16:333-339. [PMID: 34483278 PMCID: PMC9033626 DOI: 10.1097/adm.0000000000000910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Treatment of hepatitis C virus infection (HCV) with direct acting antiviral therapy is encouraged regardless of substance use status. Patients with substance use disorder are at risk of HCV reinfection after cure. Follow up viral load testing (FUVL) with HCV RNA is recommended. We investigated factors associated with adoption of FUVL in real-world clinical settings. METHODS Medical records of all patients with SUD who achieved HCV cure with direct acting antivirals at a multidisciplinary addiction treatment program between 2014 and 2019 were reviewed as part of a quality improvement initiative. Demographic and clinical characteristics including SUD treatment, urine toxicology results, and medical service use were collected. Factors associated with FUVL were analyzed and the rate of HCV reinfection was determined. RESULTS Among 149 patients, 58.4% received FUVL. Receipt of FUVL was associated with engagement in ongoing primary medical care after cure (AOR 4.39, 95% CI [1.67, 11.49]). The HCV reinfection rate among those who received FUVL was 1.95 per 100 person-years of follow up (95% CI [0.64, 5.98]). There was no significant difference in the percentage of negative urine toxicology results before and after cure. CONCLUSIONS Over half of a cohort of patients with substance use disorder cured of HCV received FUVL. The relationship between FUVL and engagement in primary medical and substance use treatment highlights the importance of integrated systems in providing longitudinal care for patients cured of HCV. Standardized interventions that facilitate FUVL testing and management of infectious complications of SUD in addiction treatment settings are needed.
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Khalsa JH, Mathur P. Hepatitis C Virus Infection in Persons Who Inject Drugs in the Middle East and North Africa: Intervention Strategies. Viruses 2021; 13:1363. [PMID: 34372569 PMCID: PMC8310161 DOI: 10.3390/v13071363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/04/2021] [Accepted: 07/11/2021] [Indexed: 12/12/2022] Open
Abstract
There is a high incidence and prevalence of hepatitis C viral infection in persons with or without substance use disorders (SUDs) in the Middle East and North Africa (MENA) region, but only a small number receive comprehensive care. Highly effective direct-acting antiviral (DAA) medications are available at substantially lower costs; however, complete elimination of the hepatitis C virus (HCV) can only be achieved if integrated care strategies target those at highest risk for HCV infection and transmission and improve access to care. Due to the high prevalence of SUD in the MENA region, strategies to eliminate HCV must focus on integrated healthcare across multiple subspecialties, including addiction medicine, psychiatry, infectious diseases, hepatology, and social work. In this invited manuscript, we review the epidemiology of HCV in the MENA region and highlight intervention strategies to attain the WHO's goal of HCV eradication by 2030.
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Affiliation(s)
- Jag H. Khalsa
- Medical Consequences of Drug Abuse and Infections Branch, Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Poonam Mathur
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
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Farnsworth CW, Lloyd M, Jean S. Opioid Use Disorder and Associated Infectious Disease: The Role of the Laboratory in Addressing Health Disparities. J Appl Lab Med 2020; 6:180-193. [PMID: 33438735 DOI: 10.1093/jalm/jfaa150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/07/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Opioid use disorder, defined as a pattern of problematic opioid use leading to clinically significant impairment, has resulted in considerable morbidity and mortality throughout the world. This is due, at least in part, to the marginalized status of patients with opioid use disorder, limiting their access to appropriate laboratory testing, diagnosis, and treatment. Infections have long been associated with illicit drug use and contribute considerably to morbidity and mortality. However, barriers to testing and negative stigmas associated with opioid use disorder present unique challenges to infectious disease testing in this patient population. CONTENT This review addresses the associations between opioid use disorder and infectious organisms, highlighting the health disparities encountered by patients with opioid use disorder, and the important role of laboratory testing for diagnosing and managing these patients. SUMMARY Infections are among the most frequent and adverse complications among patients with opioid use disorder. As a result of health disparities and systemic biases, patients that misuse opioids are less likely to receive laboratory testing and treatment. However, laboratories play a crucial in identifying patients that use drugs illicitly and infections associated with illicit drug use.
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Affiliation(s)
- Christopher W Farnsworth
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University, St. Louis, MO
| | - Matthew Lloyd
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University, St. Louis, MO
| | - Sophonie Jean
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH
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8
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Talal AH, Andrews P, Mcleod A, Chen Y, Sylvester C, Markatou M, Brown LS. Integrated, Co-located, Telemedicine-based Treatment Approaches for Hepatitis C Virus Management in Opioid Use Disorder Patients on Methadone. Clin Infect Dis 2020; 69:323-331. [PMID: 30329042 DOI: 10.1093/cid/ciy899] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/11/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Despite high hepatitis C virus (HCV) prevalence, opioid use disorder (OUD) patients on methadone rarely engage in HCV treatment. We investigated the effectiveness of HCV management via telemedicine in an opioid substitution therapy (OST) program. METHODS OUD patients on methadone underwent biweekly telemedicine sessions between a hepatologist and physician assistant during the entire HCV treatment course. All pretreatment labs (HCV RNA, genotype, and noninvasive fibrosis assessments) were obtained onsite and direct-acting antivirals were coadministered with methadone using modified directly observed therapy. We used multiple correspondence analysis, least absolute shrinkage and selection operator, and logistic regression to identify variables associated with pursuit of HCV care. RESULTS Sixty-two HCV RNA-positive patients (24% human immunodeficiency virus [HIV] infected, 61% male, 61% African American, 25.8% Hispanic) were evaluated. All patients were stabilized on methadone and all except 4 were HCV genotype 1 infected. Advanced fibrosis/cirrhosis was present in 34.5% of patients. Of the 45 treated patients, 42 (93.3%) achieved viral eradication. Of 17 evaluated patients who were not treated, 5 were discontinued from the drug treatment program or did not follow up after the evaluation, 2 had HIV adherence issues, and 10 had insurance authorization issues. Marriage and a mental health diagnosis other than depression were the strongest positive predictors of treatment pursuit, whereas being divorced, separated, or widowed was the strongest negative predictor. CONCLUSIONS HCV management via telemedicine integrated into an OST program is a feasible model with excellent virologic effectiveness. Psychosocial and demographic variables can assist in identification of subgroups with a propensity or aversion to pursue HCV treatment.
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Affiliation(s)
- Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University at Buffalo, State University of New York.,START Treatment and Recovery Centers, Brooklyn
| | | | | | - Yang Chen
- Department of Biostatistics, University at Buffalo, State University of New York
| | | | - Marianthi Markatou
- Department of Biostatistics, University at Buffalo, State University of New York
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9
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Abstract
OBJECTIVES Cirrhosis is often a consequence of substance use disorders (SUD) and can lead to significant morbidity, mortality, and hospitalizations. We aimed to determine presence and impact of SUD in recently hospitalized patients with cirrhosis, which has not been previously described. METHODS This is a retrospective study of consecutive patients with cirrhosis seen at a post-discharge hepatology clinic. The presence of clinically-recognized SUD and documented establishment of addiction treatment, as noted in routine clinical care, was determined through medical record review. Number of hospitalizations, 30-day readmissions, and all-cause mortality at 1 year were also examined. RESULTS Among 99 patients, 72% were male and the median age was 55 years. The most common etiologies of cirrhosis were alcohol-related liver disease and hepatitis C infection. Alcohol use disorder was documented in 71%. Nearly all patients with clinically-recognized SUD underwent social work evaluation during hospitalization and 65% were referred to addiction treatment. Establishment of addiction care at follow up was documented in 35%. Documented SUD was associated with greater odds of hospitalization over 1 year (adjusted odds ratio 5.77, 95% confidence interval [1.36, 24.49], P = 0.017), but not with 30-day readmissions or mortality. CONCLUSIONS Clinically-recognized SUD was common in recently hospitalized patients with cirrhosis and associated with at least 1 other hospitalization within a year. Establishment of addiction treatment was documented in only a minority of patients. Further research is needed to determine whether patients with cirrhosis and SUD experience unique barriers to addiction treatment and if integration of SUD care in hepatology settings may be beneficial.
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10
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Litwin AH, Jost J, Wagner K, Heo M, Karasz A, Feinberg J, Kim AY, Lum PJ, Mehta SH, Taylor LE, Tsui JI, Pericot-Valverde I, Page K. Rationale and design of a randomized pragmatic trial of patient-centered models of hepatitis C treatment for people who inject drugs: The HERO study. Contemp Clin Trials 2019; 87:105859. [PMID: 31669450 PMCID: PMC7261375 DOI: 10.1016/j.cct.2019.105859] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although people who inject drugs (PWID) having the highest incidence and prevalence of hepatitis C virus (HCV) in the US, HCV treatment is rarely provided to PWID due to assumptions about poor adherence and reinfection risk. As direct-acting antiviral agents (DAAs) have achieved sustained virologic response (SVR) rates of 95% or more, evidence-based strategies are urgently needed to demonstrate real-world effectiveness in marginalized patient populations such as PWID. The objectives of this study are: 1) to determine whether either of two patient-centered treatment models - patient navigation (PN) or modified directly observed therapy (mDOT) - results in more forward movement along the HCV care cascade including treatment initiation, adherence, and SVR; 2) using quantitative and qualitative methods, to understand factors associated with lack of treatment uptake, poor adherence (<80%), failure to achieve SVR, DAA resistance, and HCV reinfection. METHODS The HERO study is a multi-site, pragmatic randomized clinical trial conducted in eight states where 754 HCV-infected PWID were randomly assigned to either PN or mDOT. CONCLUSIONS This study addresses an urgent need for timely and accurate information on optimal models of care to promote HCV treatment initiation, adherence, treatment completion and SVR among PWID, as well as rates and factors associated with reinfection and resistance after treatment. This clinical trial has the potential to provide valuable information on how to reduce the burden of the HCV epidemic in PWID.
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Affiliation(s)
- Alain H Litwin
- Clemson University School of Health Research, Clemson, SC, USA; Department of Medicine, University of South Carolina School of Medicine, Greenville, SC, USA; Department of Medicine, Prisma Health, Greenville, SC, USA.
| | - John Jost
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Katherine Wagner
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Moonseong Heo
- Department of Public Health Sciences, College of Behavioral, Social, and Health Sciences, Clemson University Clemson, SC, USA
| | | | - Judith Feinberg
- Department of Behavioral Medicine & Psychiatry and Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Arthur Y Kim
- Department of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paula J Lum
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lynn E Taylor
- College of Pharmacy, University of Rhode Island, CODAC Behavioral Health, Providence, RI, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Irene Pericot-Valverde
- Clemson University School of Health Research, Clemson, SC, USA; Department of Medicine, Prisma Health, Greenville, SC, USA
| | - Kimberly Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Jessop AB, Bass SB, Brajuha J, Alhajji M, Burke M, Gashat MT, Wellington C, Ventriglia N, Coleman J, D'Avanzo P. "Take Charge, Get Cured": Pilot testing a targeted mHealth treatment decision support tool for methadone patients with hepatitis C virus for acceptability and promise of efficacy. J Subst Abuse Treat 2019; 109:23-33. [PMID: 31856947 DOI: 10.1016/j.jsat.2019.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022]
Abstract
Hepatitis C (HCV) is a highly prevalent infection in current and former IV drug users. Current estimates indicate that over 70% of those in methadone maintenance treatment programs (MMTs) have HCV, but only 11% have initiated treatments despite availability of new treatments that are easily tolerated and can cure infection in about 8 weeks. We conducted a pilot randomized trial at four Philadelphia, PA MMTs to test acceptability, feasibility and promise of efficacy of our "Take Charge, Get Cured" mobile health (mHealth) treatment decision tool, developed through extensive formative work that included methadone patients' input and targeted directly to concerns of methadone patients with Hepatitis C (HCV). We compared its impact on perceptions and knowledge about HCV and HCV treatment, decisional conflict, intention to and actual initiation of HCV care to a web-based Cochrane-reviewed, non-targeted HCV decision tool. Subjects (n = 122) were randomized, administered baseline questionnaires, interacted with the targeted or non-targeted decision tool on an electronic tablet, and answered post-test questions. After 3-months subjects (n = 93; 76%) were surveyed for follow up. "Take Charge, Get Cured" users were more likely to report the tool helped with decision making and demonstrated greater improvement in knowledge, decisional conflict, and intention to be treated for their HCV infections than users of the non-targeted decision tool. They were significantly more likely to say the targeted tool was helpful and that they would recommend it to others. At three month follow up, targeted group participants were more likely to say the tool helped them make a better decision about treatment and prepared them to talk to their doctor about what matters most to them about treatment. No differences were seen in actions to initiate HCV care, but more targeted group participants reported talking to their doctors about HCV treatment. Results indicate a highly targeted mHealth decision tool is an important strategy to affect perceptions and knowledge of HCV treatment that lowers decisional conflict about initiating treatment, key components in decision making. We believe this highly acceptable and feasible intervention could be utilized in clinical settings to address the important barriers to initiating HCV treatment in a vulnerable population.
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Affiliation(s)
- Amy B Jessop
- Western Michigan University, Public health Program, 200 Ionia Ave, NW, 4th Floor, Grand Rapids, MI 49503, USA; HepTREC, 141 Whitemarsh Rd, Ardmore, PA 19003, USA.
| | - Sarah Bauerle Bass
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Jesse Brajuha
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Mohammed Alhajji
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Monika Burke
- HepTREC, 141 Whitemarsh Rd, Ardmore, PA 19003, USA
| | | | - Carine Wellington
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Nicole Ventriglia
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Jennie Coleman
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
| | - Paul D'Avanzo
- Temple University, Department of Social and Behavioral Sciences, Risk Communication Laboratory, College of Public Health, Ritter Annex, Philadelphia, PA 19122, USA
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Lazarus JV, Pericàs JM, Picchio C, Cernosa J, Hoekstra M, Luhmann N, Maticic M, Read P, Robinson EM, Dillon JF. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019; 286:503-525. [PMID: 31472002 DOI: 10.1111/joim.12972] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.
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Affiliation(s)
- J V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J M Pericàs
- Infectious Diseases and Clinical Microbiology Territorial Direction, Translational Research Group on Infectious Diseases of Lleida (TRIDLE), Biomedical Research Institute Dr Pifarré Foundation, Lleida, Spain
| | - C Picchio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J Cernosa
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Hoekstra
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - N Luhmann
- Médecins du Monde France, Paris, France
| | - M Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Read
- Kirketon Road Centre, Sydney, NSW, Australia
| | - E M Robinson
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - J F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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13
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Integrated Care for the Use of Direct-acting Antivirals in Patients With Chronic Hepatitis C and Substance Use Disorder. J Addict Med 2019; 12:346-352. [PMID: 29702515 DOI: 10.1097/adm.0000000000000415] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Since little is currently known about predictors of response to direct-acting antiviral agents (DAAs) in people who inject drugs, we undertook an analysis of patients attending a hepatitis clinic with addiction services (outpatient clinics and inpatient services) to examine the outcomes associated with the treatment of difficult-to-manage patients with substance use. Our experience was based on integrated care. METHOD A retrospective analysis was undertaken of 50 patients with hepatitis C virus (HCV) and a history of addiction who received treatment with DAAs, according to European guidelines. These regimens were sofosbuvir/ledipasvir for 8 weeks (n = 3), sofosbuvir/ledipasvir ± ribavirin for 12 weeks (n = 19), sofosbuvir/daclatasvir for 12 weeks (n = 20), sofosbuvir/simeprevir (n = 1), or sofosbuvir/daclatasvir for 24 weeks (n = 7). Characteristics of patients who did versus did not achieve a sustained virologic response (SVR) 12 weeks after treatment were compared by univariate analysis. RESULTS Forty-two patients (84%) were male; mean age was 46.2 ± 7.3 years. Genotypes were 1 (n = 21), 2 (n = 4), 3 (n = 18), 4 (n = 6), or 6 (n = 1). Most patients were treatment-naïve (n = 38). Five patients had coinfection with human immunodeficiency virus (n = 4) or hepatitis B (n = 1), 28 (56%) had evidence of cirrhosis on FibroScan (>12.5 kPa), and 34 (68%) were receiving opioid substitution therapy. Psychiatric disease, illicit drug use, unemployment, and homelessness/precarious housing were common. Forty-five patients (90%) achieved SVR, 2 were lost to follow-up, and 3 had treatment relapse. CONCLUSIONS SVR was not significantly associated with sociodemographic or virological characteristics, treatment, social environment, alcohol/drug use, and adherence. Although adherence was slightly worse than in "usual" patients, it did not affect the SVR rate. In these difficult-to-manage patients with HCV and substance use disorder, the real-world SVR rate (90%) was similar to that in nonaddicted populations.
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14
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Socías ME, Karamouzian M, Parent S, Barletta J, Bird K, Ti L. Integrated models of care for people who inject drugs and live with hepatitis C virus: A systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:146-159. [PMID: 31147142 DOI: 10.1016/j.drugpo.2019.05.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite the key role that people who inject drugs (PWID) play in the hepatitis C virus (HCV) epidemic, HCV treatment rates among this population have been historically low. Integrated models of HCV and substance use care have the potential to overcome some barriers to access; however, the evidence base is uncertain. This systematic review assesses the impacts of integrated HCV and substance use services on engagement in HCV care among PWID. METHODS We searched five databases up to December 2018 to identify original quantitative studies evaluating the impacts of co-location of HCV and substance use services on engagement in the HCV cascade of care among adult PWID. We conducted a narrative synthesis, categorizing models based on patient entry point (a: HCV facility, b: substance use disorder (SUD) facility, and c: other facilities), and levels of integrated services offered (a: HCV/substance use testing only, b: HCV/substance use treatment, and c: testing/treatment + other services). RESULTS A total of 46 articles corresponding to 44 original studies were included. Almost all studies (n = 42) were conducted in high-income countries and only six studies in the Direct-Acting Antiviral (DAA) era. Twenty-six studies discussed the integration of services at SUD facilities, one at HCV facilities, and seventeen at other facilities. Analysis of included studies indicated that overall integrated care resulted in improved engagement in HCV care (e.g., testing, treatment uptake and cure). However, the quality of evidence was predominantly low to moderate. CONCLUSIONS Available evidence suggests that integration of HCV and substance use services may improve engagement along the continuum of HCV care among PWID. Given limitations in data quality, and very few studies conducted in the DAA era and in low- and middle-income settings, further research is urgently needed to inform strategies to optimize HCV care access and outcomes among PWID globally.
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Affiliation(s)
- M Eugenia Socías
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Mohammad Karamouzian
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, 7616911320, Iran
| | - Stephanie Parent
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - José Barletta
- Infectious Diseases Division, Hospital Juan A. Fernández, Cerviño 3356, Buenos Aires, C1425AGP, Argentina
| | - Kathleen Bird
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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15
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Tai CM, Yen YC, Bair MJ, Tseng CH, Chang TT, Huang CF, Yeh ML, Dai CY, Chuang WL, Yu ML, Huang JF. Integrated care for methadone maintenance patients with hepatitis C virus infection. Kaohsiung J Med Sci 2019; 35:501-507. [PMID: 31087764 DOI: 10.1002/kjm2.12086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/29/2019] [Indexed: 01/14/2023] Open
Abstract
The majority of patients undergoing methadone maintenance treatment (MMT) are neither examined nor treated for hepatitis C virus (HCV) infection. We aimed to evaluate an integrated referral model in the management of HCV among MMT patients. This retrospective study included 390 HCV-infected MMT patients between April 2015 and May 2017. Patients who tested positive for HCV antibodies were referred to a liver clinic by MMT case managers or psychiatrists. Patients who agreed to receive anti-HCV treatment were treated with pegylated interferon and ribavirin. The rate of patient engagement at a liver clinic increased from 14.1% to 58.2% after integrated care. Multiple logistic regression analysis showed that higher education level (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.01-2.60) and elevated ALT level (OR, 4.30; 95% CI, 2.70-6.85) were independently associated with patients who accepted referral. Active drug use (OR, 0.52; 95% CI, 0.31-0.85) was inversely associated with referral acceptance. Of the 112 patients who met the criteria for anti-HCV therapy, 66 (58.9%) were treated with pegylated interferon and ribavirin. Finally, the rate of treatment completion and sustained virological response (SVR) was 65.2% and 54.5%, respectively, among the 66 patients. Treatment completion (OR, 39.67; 95% CI, 7.80-201.62) was found to be the only independent factor associated with SVR achievement. Although integrated care by psychiatrists and hepatologists significantly increased the rates of engagement and acceptance of antiviral treatment for HCV-infected MMT patients, only a minority of MMT patients achieved successful treatment.
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Affiliation(s)
- Chi-Ming Tai
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Chieh Yen
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Department of Psychiatry, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Ming-Jong Bair
- Division of Gastroenterology, Department of Internal Medicine, Taitung Mackay Memorial Hospital, Taiwan.,Mackay Medical College, New Taipei City, Taiwan
| | - Cheng-Hao Tseng
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ting-Ting Chang
- Department of Psychiatry, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chung-Feng Huang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Lun Yeh
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chia-Yen Dai
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wan-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Internal Medicine, School of Medicine, College of Medicine, and Lipid Science and Aging Research Center, and Center for Infectious Disease and Cancer Research, Kaohsiung Medical University, Kaohsiung, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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16
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Childs E, Assoumou SA, Biello KB, Biancarelli DL, Drainoni ML, Edeza A, Salhaney P, Mimiaga MJ, Bazzi AR. Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs. Harm Reduct J 2019; 16:14. [PMID: 30744628 PMCID: PMC6371610 DOI: 10.1186/s12954-019-0286-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population. METHODS We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods. RESULTS In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment. CONCLUSIONS Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.
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Affiliation(s)
- Ellen Childs
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Sabrina A Assoumou
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Katie B Biello
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Alberto Edeza
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Peter Salhaney
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
| | - Matthew J Mimiaga
- Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA
- Departments of Behavioral and Social Health Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 442e, Boston, MA, 02118, USA.
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17
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Roncero C, Ryan P, Littlewood R, Macías J, Ruiz J, Seijo P, Palma-Álvarez RF, Vega P. Practical steps to improve chronic hepatitis C treatment in people with opioid use disorder. Hepat Med 2018; 11:1-11. [PMID: 30613166 PMCID: PMC6307489 DOI: 10.2147/hmer.s187133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES People with a history of injecting drugs have high prevalence of hepatitis C virus (HCV) infection, and many have opioid use disorder (OUD). Modern HCV therapies with improved efficacy and tolerability are available, but access is often limited for this group, who may be underserved for health care and face social inequity. This work develops practical steps to improve HCV care in this population. METHODS Practical steps to improve HCV care in OUD populations were developed based on clinical experience from Spain, structured assessment of published evidence. RESULTS Options for improving care at engagement/screening stages include patient education programs, strong provider-patient relationship, peer support, and adoption of rapid effective screening tools. To facilitate work up/treatment, start options include simplified work up process, integration of HCV and OUD care, and continuous psychosocial support prior, during, and after HCV treatment. CONCLUSION It is important to plan on local basis to set up a joint integrated approach between specific drug treatment services and local points of HCV care. The elements for a specific integrated program should be chosen from options identified, including education services, peer input, organization to make HCV screening and treatment easier by co-location of services, and wider access to prescribing direct-acting antiviral (DAA) therapy.
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Affiliation(s)
- Carlos Roncero
- Psychiatric Service, University of Salamanca Health Care Complex, Institute of Biomedicine of Salamanca, University of Salamanca, Salamanca, Spain,
| | - Pablo Ryan
- Internal Medicine Service, University Hospital Infanta Leonor, Madrid, Spain
- School of Medicine, Complutense University of Madrid, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | | | - Juan Macías
- Department of Infectious Diseases and Microbiology, Valme University Hospital, Seville, Spain
| | - Juan Ruiz
- Provincial Center of Drug Addiction, Malaga, Spain
| | - Pedro Seijo
- Addiction Treatment Center of Villamartín, Cádiz, Spain
| | - Raúl Felipe Palma-Álvarez
- Addiction and Dual Diagnosis Unit, Vall Hebron University Hospital, Barcelona, Spain
- Psychiatry Service, Biomedical Research Networking Center for Mental Health Network, Vall Hebron University Hospital, Barcelona, Spain
- Autonomous University of Barcelona, Barcelona, Spain
| | - Pablo Vega
- Spanish Society of Dual Diagnosis, Bilbao, Spain
- Institute of Addictions, Madrid, Spain
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18
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Evon DM, Stewart PW, Amador J, Serper M, Lok AS, Sterling RK, Sarkar S, Golin CE, Reeve BB, Nelson DR, Reau N, Lim JK, Reddy KR, Di Bisceglie AM, Fried MW. A comprehensive assessment of patient reported symptom burden, medical comorbidities, and functional well being in patients initiating direct acting antiviral therapy for chronic hepatitis C: Results from a large US multi-center observational study. PLoS One 2018; 13:e0196908. [PMID: 30067745 PMCID: PMC6070182 DOI: 10.1371/journal.pone.0196908] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Symptom burden, medical comorbidities, and functional well-being of patients with chronic hepatitis C virus (HCV) initiating direct acting antiviral (DAA) therapy in real-world clinical settings are not known. We characterized these patient-reported outcomes (PROs) among HCV-infected patients and explored associations with sociodemographic, liver disease, and psychiatric/substance abuse variables. METHODS AND FINDINGS PROP UP is a large US multicenter observational study that enrolled 1,600 patients with chronic HCV in 2016-2017. Data collected prior to initiating DAA therapy assessed the following PROs: number of medical comorbidities; neuropsychiatric, somatic, gastrointestinal symptoms (PROMIS surveys); overall symptom burden (Memorial Symptom Assessment Scale); and functional well-being (HCV-PRO). Candidate predictors included liver disease markers and patient-reported sociodemographic, psychiatric, and alcohol/drug use features. Predictive models were explored using a random selection of 700 participants; models were then validated with data from the remaining 900 participants. The cohort was 55% male, 39% non-white, 48% had cirrhosis (12% with advanced cirrhosis); 52% were disabled or unemployed; 63% were on public health insurance or uninsured; and over 40% had markers of psychiatric illness. The median number of medical comorbidities was 4 (range: 0-15), with sleep disorders, chronic pain, diabetes, joint pain and muscle aches being present in 20-50%. Fatigue, sleep disturbance, pain and neuropsychiatric symptoms were present in over 60% and gastrointestinal symptoms in 40-50%. In multivariable validation models, the strongest and most frequent predictors of worse PROs were disability, unemployment, and use of psychiatric medications, while liver markers generally were not. CONCLUSIONS This large multi-center cohort study provides a comprehensive and contemporary assessment of the symptom burden and comorbid medical conditions in patients with HCV treated in real world settings. Pain, fatigue, and sleep disturbance were common and often severe. Sociodemographic and psychiatric markers were the most robust predictors of PROs. Future research that includes a rapidly changing population of HCV-infected individuals needs to evaluate how DAA therapy affects PROs and elucidate which symptoms resolve with viral eradication. TRIAL REGISTRATION (Clinicaltrial.gov: NCT02601820).
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Affiliation(s)
- Donna M. Evon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Paul W. Stewart
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jipcy Amador
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Anna S. Lok
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Richard K. Sterling
- Division of Gastroenterology, Hepatology & Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Souvik Sarkar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California Davis, Davis, California, United States of America
| | - Carol E. Golin
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Department of Health Behaviors, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Bryce B. Reeve
- Department of Population Health Sciences, Duke University, Durham, North Carolina, United States of America
| | - David R. Nelson
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Nancy Reau
- Department of Internal Medicine, Section of Hepatology, Rush University, Chicago, Illinois, United States of America
| | - Joseph K. Lim
- Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut, United States of America
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Adrian M. Di Bisceglie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Saint Louis University, St. Louis, Missouri, United States of America
| | - Michael W. Fried
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America
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19
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Norton BL, Akiyama MJ, Zamor PJ, Litwin AH. Treatment of Chronic Hepatitis C in Patients Receiving Opioid Agonist Therapy: A Review of Best Practice. Infect Dis Clin North Am 2018; 32:347-370. [PMID: 29778260 PMCID: PMC6022838 DOI: 10.1016/j.idc.2018.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Injection drug use is the most common transmission route for hepatitis C. High rates of infection are observed among individuals on opioid agonist therapy. Although people who inject drugs carry the highest burden, few have initiated treatment. We present a comprehensive review of the evidence on the efficacy of HCV medications, drug-drug interactions, and barriers to and models of care. Studies have demonstrated comparable efficacy for individuals who are on opioid agonist therapy compared with those who are not. We propose that a strategy of treatment and cure-as-prevention is imperative in this population to curb the hepatitis C epidemic.
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Affiliation(s)
- Brianna L Norton
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467, USA.
| | - Matthew J Akiyama
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467, USA
| | - Philippe J Zamor
- Division of Hepatology, Carolinas Healthcare Systems, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - Alain H Litwin
- Division of General Internal Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467, USA
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20
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Patel K, Maguire E, Chartier M, Akpan I, Rogal S. Integrating Care for Patients With Chronic Liver Disease and Mental Health and Substance Use Disorders. Fed Pract 2018; 35:S14-S23. [PMID: 30766391 PMCID: PMC6375404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Mental health disorders are common among patients with chronic liver disease, and current literature supports the use of better screening and providing integrated or multidisciplinary care where possible.
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Affiliation(s)
- Krupa Patel
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Elizabeth Maguire
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Maggie Chartier
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Imo Akpan
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
| | - Shari Rogal
- is an Assistant Professor and is a Resident at University of Pittsburgh in Pennsylvania. is a Gastroenterologist at Baylor Scott & White Health, Texas. is a Health Communications Researcher at the Center for Healthcare Organization and Implementation Research at Bedford VAMC in Massachusetts. is the Deputy Director and the National Infectious Diseases Officer and Ms. Maguire is Communications Lead at the Veterans Health Administration, Office of Specialty Care Services, HIV, Hepatitis, and Related Conditions Programs. Dr. Rogal is a Gastroenterologist, Transplant Hepatologist, and an Investigator at the Center for Health Equity Research and Promotion at VA Pittsburgh Healthcare System
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Perumalswami PV, Talal AH. Improvements in Quality of Life: A New Indication for Treating Hepatitis C Virus Infection in Persons With Substance Use Disorders. J Infect Dis 2017; 217:1020-1023. [DOI: 10.1093/infdis/jix682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ponni V Perumalswami
- Division of Hepatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, University at Buffalo, State University of New York, Buffalo, New York
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Bajis S, Dore GJ, Hajarizadeh B, Cunningham EB, Maher L, Grebely J. Interventions to enhance testing, linkage to care and treatment uptake for hepatitis C virus infection among people who inject drugs: A systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 47:34-46. [DOI: 10.1016/j.drugpo.2017.07.002] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/17/2017] [Accepted: 07/10/2017] [Indexed: 12/26/2022]
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Talal AH, Thomas DL, Reynolds JL, Khalsa JH. Toward Optimal Control of Hepatitis C Virus Infection in Persons With Substance Use Disorders. Ann Intern Med 2017; 166:897-898. [PMID: 28437796 PMCID: PMC10530641 DOI: 10.7326/m16-2887] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Andrew H Talal
- From the University at Buffalo, The State University of New York, Buffalo, New York; Johns Hopkins University School of Medicine, Baltimore, Maryland; and the National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Dave L Thomas
- From the University at Buffalo, The State University of New York, Buffalo, New York; Johns Hopkins University School of Medicine, Baltimore, Maryland; and the National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jessica L Reynolds
- From the University at Buffalo, The State University of New York, Buffalo, New York; Johns Hopkins University School of Medicine, Baltimore, Maryland; and the National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jag H Khalsa
- From the University at Buffalo, The State University of New York, Buffalo, New York; Johns Hopkins University School of Medicine, Baltimore, Maryland; and the National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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Gonzalez SA, Fierer DS, Talal AH. Medical and Behavioral Approaches to Engage People Who Inject Drugs Into Care for Hepatitis C Virus Infection. ADDICTIVE DISORDERS & THEIR TREATMENT 2017; 16:S1-S23. [PMID: 28701904 PMCID: PMC5491232 DOI: 10.1097/adt.0000000000000104] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Direct-acting antivirals for hepatitis C virus infection may revolutionize treatment among persons with substance use disorders. Despite persons with substance use disorders having the highest hepatitis C virus prevalence and incidence, the vast majority have not engaged into care for the infection. Previously, interferon-based treatments, with substantial side effects and the propensity to exacerbate mental health conditions, were major disincentives to pursuit of care for the infection. Direct-acting antivirals with viral eradication rates of >90%, significantly improved side effect profiles, and shorter treatment duration are dramatic improvements over prior treatment regimens that should promote widespread hepatitis C virus care among persons with substance use disorders. The major unmet need is strategies to promote persons with substance use disorders engagement into care for hepatitis C virus. Although physical integration of treatment for substance use and co-occurring conditions has been widely advocated, it has been difficult to achieve. Telemedicine offers an opportunity for virtual integration of behavioral and medical treatments that could be supplemented by conventional interventions such as hepatitis C virus education, case management, and peer navigation. Furthermore, harm reduction and strategies to reduce viral transmission are important to cease reinfection among persons with substance use disorders. Widespread prescription of therapy for hepatitis C virus infection to substance users will be required to achieve the ultimate goal of global virus elimination. Combinations of medical and behavioral interventions should be used to promote persons with substance use disorders engagement into and adherence with direct-acting antiviral-based treatment approaches. Ultimately, either physical or virtual colocation of hepatitis C virus and substance use treatment has the potential to improve adherence and consequently treatment efficacy.
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Affiliation(s)
- Stevan A. Gonzalez
- Division of Hepatology, Baylor Simmons Transplant Institute, Fort Worth, TX
| | | | - Andrew H. Talal
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Jacobs School of Medicine, State University of New York at Buffalo, Buffalo, NY
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Dillon JF, Lazarus JV, Razavi HA. Urgent action to fight hepatitis C in people who inject drugs in Europe. HEPATOLOGY, MEDICINE AND POLICY 2016; 1:2. [PMID: 30288305 PMCID: PMC5918492 DOI: 10.1186/s41124-016-0011-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/20/2016] [Indexed: 12/19/2022]
Abstract
Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and liver cancer, is curable in most people. Injecting drug use currently accounts for 80 % of new HCV infections with a known transmission route in the European Union (EU). HCV has generally received little attention from the public or policymakers in the EU, with major gaps in national-level strategies, action plans, guidelines and the evidence base. Specifically, people who inject drugs (PWID) are often excluded from treatment owing to various patient, healthcare provider and health system factors. All policymakers responsible for health services in EU countries should ensure that prevention, treatment, care and support interventions addressing HCV in PWID are developed and implemented. According to current best practice, PWID should have access to comprehensive, evidence-based multiprofessional harm reduction (especially opioid substitution therapy and clean needles and syringes) and support/care services based in the community and modified with community involvement to accommodate this hard-to-reach population. Other recommended components of care include vaccination against hepatitis B and other infections; peer support interventions; HIV testing, prevention and treatment; drug and alcohol services; psychological care as needed; and social support services. HCV testing should be performed regularly in PWID to identify infected persons and engage them in care. HCV-infected PWID should be considered for antiviral treatment (based on an individualised assessment and delivered within multidisciplinary care/support programmes) both to cure infected individuals and prevent onward transmission. Modelling data suggest that the HCV disease burden can only be cut substantially if antiviral treatment is scaled up together with prevention programmes. Measures should be taken to reduce stigma and discrimination against PWID at the provider and institutional levels. In conclusion, strategic action at the policy level is urgently needed to increase access to HCV prevention, testing and treatment among PWID, the group at highest risk of HCV infection. Such action has the potential to substantially reduce the number of infected persons, along with the disease burden and related care costs.
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Affiliation(s)
- John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, UK
| | - Jeffrey V Lazarus
- 2Centre for Health and Infectious Disease Research (CHIP) and WHO Collaborating Centre on HIV and Viral Hepatitis, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Kirby BJ, Symonds WT, Kearney BP, Mathias AA. Pharmacokinetic, Pharmacodynamic, and Drug-Interaction Profile of the Hepatitis C Virus NS5B Polymerase Inhibitor Sofosbuvir. Clin Pharmacokinet 2016; 54:677-90. [PMID: 25822283 DOI: 10.1007/s40262-015-0261-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sofosbuvir (SOVALDI(®)), a potent, once-daily, orally administered nucleotide analog prodrug inhibitor of the hepatitis C virus (HCV) NS5B polymerase is approved in the USA, EU, Canada, and other regions for the treatment of HCV infection as a component of an antiviral treatment regimen. Sofosbuvir undergoes intracellular activation to form GS-461203 (active triphosphate, not detected in plasma), and ultimately the inactive, renally eliminated metabolite GS-331007. GS-331007 was identified as the primary analyte of interest for clinical pharmacology studies as it accounted for >90 % of systemic drug-related material exposure, and provided comparable exposure-response relationships for viral kinetics as observed for sofosbuvir. GS-331007 and sofosbuvir exhibit linear pharmacokinetics with minimal accumulation upon multiple dosing. Compared to healthy subjects, HCV-infected patients had modestly lower (39 %) GS-331007 area under the plasma concentration-time curve (AUC) and higher sofosbuvir AUC (60 %). Sofosbuvir can be administered without dose modification in HCV-infected patients with any degree of hepatic impairment or mild to moderate renal impairment. Sofosbuvir has a low propensity for clinically significant drug interactions with common concomitant medications used by HCV-infected patients. Clinically significant alterations in GS-331007 or sofosbuvir exposures are limited to potent inducers of intestinal P-glycoprotein that may lower exposure. In HCV-infected patients, demographic variables do not significantly influence GS-331007 and sofosbuvir exposures and no consistent exposure-response relationships were observed for efficacy or safety. This review focuses on the clinical pharmacokinetics, pharmacodynamics, and pharmacokinetic-pharmacodynamic relationships of sofosbuvir, and summarizes a number of drug interaction studies with important concomitant medications commonly used by HCV-infected patients.
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Affiliation(s)
- Brian J Kirby
- Gilead Sciences Inc., 333 Lakeside Drive, Foster City, CA, 94404, USA
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Hepatitis C virus-related knowledge and willingness to receive treatment among patients on methadone maintenance. J Addict Med 2016; 8:249-57. [PMID: 24820257 DOI: 10.1097/adm.0000000000000041] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although persons who inject drugs have high prevalence of hepatitis C virus (HCV) infection, few receive treatment mostly because of lack of knowledge about the infection and its treatment. We assessed the level of HCV-related knowledge and willingness to participate in HCV treatment among methadone-maintained patients. METHODS A 30-item survey covering HCV-related knowledge and willingness to engage in HCV-related education and treatment was developed and completed by 320 methadone-maintained patients. RESULTS Respondents' mean age was 53 ± 8.7 years, 59.5% were male, 55.1% were African American, and 38.3% were Hispanic. The mean duration of methadone maintenance was 7 ± 6.7 years. In the preceding 6 months, 6.9% of patients reported injection drug use, whereas 37.3% used noninjection drugs. Hepatitis C virus seropositivity was self-reported by 46.3% of patients. The majority of patients (78%) expressed willingness to participate in HCV-related education and to receive HCV treatment. Most patients (54.7%) correctly answered 5 or more of 7 questions assessing HCV knowledge. Hepatitis C virus-seropositive individuals and prior attendees at HCV-related educational activities demonstrated a higher level of HCV-related knowledge (P < 0.001 and P = 0.002, respectively). Younger patients (P = 0.014), those willing to attend an HCV-related educational activity (P < 0.001), and those with higher-HCV-related knowledge (P = 0.029) were more accepting of HCV treatment. Fear of medication-related side effects was the most common reason for treatment avoidance. CONCLUSIONS The majority of patients reported willingness to receive HCV-related education and treatment. Treatment willingness was significantly associated with previous attendance at an HCV educational activity and a higher level of HCV-related knowledge.
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Hom JK, Witt C, Johnson CC, Viner K. Demographic, risk factor, and provider characteristics associated with confirmatory hepatitis C testing. Ann Epidemiol 2015; 26:157-159. [PMID: 26733081 DOI: 10.1016/j.annepidem.2015.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 11/28/2015] [Indexed: 12/19/2022]
Affiliation(s)
- Jeffrey K Hom
- Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA; Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
| | - Christine Witt
- Philadelphia Department of Public Health, Philadelphia, PA
| | | | - Kendra Viner
- Philadelphia Department of Public Health, Philadelphia, PA
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Wade AJ, Macdonald DM, Doyle JS, Gordon A, Roberts SK, Thompson AJ, Hellard ME. The Cascade of Care for an Australian Community-Based Hepatitis C Treatment Service. PLoS One 2015; 10:e0142770. [PMID: 26562516 PMCID: PMC4642931 DOI: 10.1371/journal.pone.0142770] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/27/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hepatitis C treatment uptake in Australia is low. To increase access to hepatitis C virus treatment for people who inject drugs, we developed a community-based, nurse-led service that linked a viral hepatitis service in a tertiary hospital to primary care clinics, and resulted in hepatitis C treatment provision in the community. METHODS A retrospective cohort study of patients referred to the community hepatitis service was undertaken to determine the cascade of care. Logistic regression analyses were used to identify predictors of hepatitis C treatment uptake. RESULTS Four hundred and sixty-two patients were referred to the community hepatitis service; 344 attended. Among the 279 attendees with confirmed chronic hepatitis C, 257 (99%) reported ever injecting drugs, and 124 (48%) injected in the last month. Of 201 (72%) patients who had their fibrosis staged, 63 (31%) had F3-F4 fibrosis. Fifty-five patients commenced hepatitis C treatment; 26 (47%) were current injectors and 25 (45%) had F3-F4 fibrosis. Nineteen of the 27 (70%) genotype 1 patients and 14 of the 26 (54%) genotype 3 patients eligible for assessment achieved a sustained virologic response. Advanced fibrosis was a significant predictor of treatment uptake in adjusted analysis (AOR 2.56, CI 1.30-5.00, p = 0.006). CONCLUSIONS Our community hepatitis service produced relatively high rates of fibrosis assessment, hepatitis C treatment uptake and cure, among people who inject drugs. These findings highlight the potential benefits of providing community-based hepatitis C care to people who inject drugs in Australia-benefits that should be realised as direct-acting antiviral agents become available.
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Affiliation(s)
- Amanda J. Wade
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia
| | - Diana M. Macdonald
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
| | - Joseph S. Doyle
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Gordon
- Department of Gastroenterology, The Alfred, Melbourne, Victoria, Australia
| | - Stuart K. Roberts
- Department of Gastroenterology, The Alfred, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alexander J. Thompson
- Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Margaret E. Hellard
- Centre for Population Health, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recomendaciones para el manejo de la infección por el virus de la hepatitis C entre usuarios de drogas por vía parenteral. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015. [DOI: 10.1016/j.drugpo.2015.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Milne R, Price M, Wallace B, Drost A, Haigh-Gidora I, Nezil FA, Fraser C. From principles to practice: Description of a novel equity-based HCV primary care treatment model for PWID. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1020-7. [DOI: 10.1016/j.drugpo.2015.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 07/09/2015] [Accepted: 07/13/2015] [Indexed: 12/11/2022]
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Grebely J, Robaeys G, Bruggmann P, Aghemo A, Backmund M, Bruneau J, Byrne J, Dalgard O, Feld JJ, Hellard M, Hickman M, Kautz A, Litwin A, Lloyd AR, Mauss S, Prins M, Swan T, Schaefer M, Taylor LE, Dore GJ. Recommendations for the management of hepatitis C virus infection among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1028-38. [PMID: 26282715 PMCID: PMC6130980 DOI: 10.1016/j.drugpo.2015.07.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 02/07/2023]
Abstract
In high income countries, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). In many low and middle income countries large HCV epidemics have also emerged among PWID populations. The burden of HCV-related liver disease among PWID is increasing, but treatment uptake remains extremely low. There are a number of barriers to care which should be considered and systematically addressed, but should not exclude PWID from HCV treatment. The rapid development of interferon-free direct-acting antiviral (DAA) therapy for HCV infection has brought considerable optimism to the HCV sector, with the realistic hope that therapeutic intervention will soon provide near optimal efficacy with well-tolerated, short duration, all oral regimens. Further, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provide a framework for HCV assessment and care. Further research is needed to evaluate strategies to enhance testing, linkage to care, treatment, adherence, viral cure, and prevent HCV reinfection among PWID, particularly as new interferon-free DAA treatments for HCV infection become available.
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Affiliation(s)
| | - 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, Limburg Clinical Research Program, Hasselt University, Hasselt, Belgium
| | | | - Alessio Aghemo
- A.M. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Markus Backmund
- Ludwig-Maximilians-University, Munich, Germany; Praxiszentrum im Tal Munich, Munich, Germany
| | | | - Jude Byrne
- International Network of People who Use Drugs, Canberra, Australia
| | - Olav Dalgard
- Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Margaret Hellard
- Burnet Institute, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew Hickman
- School of Social & Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Achim Kautz
- European Liver Patients Association, Cologne, Germany
| | - Alain Litwin
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Andrew R Lloyd
- Inflammation and Infection Research Centre, School of Medical Sciences, UNSW Australia, Sydney, Australia
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Maria Prins
- Department of Research, Cluster Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, The Netherlands; Department of Internal Medicine, CINIMA, Academic Medical Centre, Amsterdam, The Netherlands
| | - Tracy Swan
- Treatment Action Group, New York, United States
| | - Martin Schaefer
- Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany; Department of Psychiatry and Psychotherapy-CCM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lynn E Taylor
- Department of Medicine, Brown University, Providence, RI, United States
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Perlman DC, Jordan AE, McKnight C, Young C, Delucchi KL, Sorensen JL, Des Jarlais DC, Masson CL. Viral hepatitis among drug users in methadone maintenance: associated factors, vaccination outcomes, and interventions. J Addict Dis 2015; 33:322-31. [PMID: 25299236 DOI: 10.1080/10550887.2014.969623] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Drug users are at high risk of viral Hepatitis A, B, and C. The prevalence of Hepatitis A, Hepatitis B, and Hepatitis C, associated factors, and vaccine seroconversion among drug treatment program participants in a randomized controlled trial of hepatitis care coordination were examined. Of 489 participants, 44 and 47% required Hepatitis A/Hepatitis B vaccinations, respectively; 59% were Hepatitis C positive requiring linkage to care. Factors associated with serologic statuses, and vaccine seroconversion are reported; implications for strategies in drug treatment settings are discussed. Results suggest generalizable strategies for drug treatment programs to expand viral hepatitis screening, prevention, vaccination, and linkage to care.
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Affiliation(s)
- David C Perlman
- a Chemical Dependency Institute, Mount Sinai Beth Israel , New York , New York , USA
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Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:922-35. [PMID: 26077144 DOI: 10.1016/j.drugpo.2015.05.002] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/21/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND With the explosion of newly available direct acting antiviral (DAA) Hepatitis C virus (HCV) treatments that demonstrate 95% sustained virologic response (SVR) rates, evidence-based strategies are urgently needed to achieve real-world effectiveness in challenging patient populations. While HIV is incurable, lessons from over 30 years of experience overcoming obstacles to the HIV treatment cascade could be applied to the HCV context. METHODS Using Institute of Medicine guidelines, we conducted a systematic review of published interventions from PubMed, Medline, GoogleScholar, EmBASE, and PsychInfo bibliographic databases and citation indices. Abstracts were first screened by three independent reviewers and studies were included if they involved original research, described a specific intervention, were published in English in a peer-reviewed journal between 2001 and 2014, and had full text available. RESULTS Evidence-based interventions to enhance HCV assessment, treatment, and adherence generally fell into one of 4 categories, including those involving: (1) diagnosis or case-finding; (2) linkage to HCV care; (3) pre-therapeutic evaluation or treatment initiation; or (4) treatment adherence. While most available eligible studies described interventions using non-contemporary interferon-based HCV treatments, future research will need to address how these interventions apply to the context of well-tolerated, simple, oral treatment regimens. In some cases, we explored how HIV-specific interventions might be modified to fit the HCV spectrum of care engagement. CONCLUSIONS Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes.
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Arain A, Robaeys G. Eligibility of persons who inject drugs for treatment of hepatitis C virus infection. World J Gastroenterol 2014; 20:12722-12733. [PMID: 25278674 PMCID: PMC4177459 DOI: 10.3748/wjg.v20.i36.12722] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
In this decade, an increase is expected in end-stage liver disease and hepatocellular carcinoma, most commonly caused by hepatitis C virus (HCV) infection. Although people who inject drugs (PWID) are the major source for HCV infection, they were excluded from antiviral treatments until recently. Nowadays there is incontrovertible evidence in favor of treating these patients, and substitution therapy and active substance use are no longer contraindications for antiviral treatment. The viral clearance in PWID after HCV antiviral treatment with interferon or pegylated interferon combined with ribavirin is comparable to the viral clearance in non-substance users. Furthermore, multidisciplinary approaches to delivering treatment to PWID are advised, and their treatment should be considered on an individualized basis. To prevent the spread of HCV in the PWID community, recent active PWID are eligible for treatment in combination with needle exchange programs and substitution therapy. As the rate of HCV reinfection is low after HCV antiviral treatment, there is no need to withhold HCV treatment due to concerns about reinfection alone. Despite the advances in treatment efficacies and data supporting their success, HCV assessment of PWID and initiation of antiviral treatment remains low. However, the proportion of PWID assessed and treated for HCV is increasing, which can be further enhanced by understanding the barriers to and facilitators of HCV care. Removing stigmatization and implementing peer support and group treatment strategies, in conjunction with greater involvement by nurse educators/practitioners, will promote greater treatment seeking and adherence by PWID. Moreover, screening can be facilitated by noninvasive methods for detecting HCV antibodies and assessing liver fibrosis stages. Recently, HCV clearance has become a major endpoint in the war against drugs for the Global Commission on Drug Policy. This review highlights the most recent evidence concerning HCV infection and treatment strategies in PWID.
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Niederau C, Mauss S, Schober A, Stoehr A, Zimmermann T, Waizmann M, Moog G, Pape S, Weber B, Isernhagen K, Sandow P, Bokemeyer B, Alshuth U, Steffens H, Hüppe D. Predictive factors for sustained virological response after treatment with pegylated interferon α-2a and ribavirin in patients infected with HCV genotypes 2 and 3. PLoS One 2014; 9:e107592. [PMID: 25238535 PMCID: PMC4169557 DOI: 10.1371/journal.pone.0107592] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 08/12/2014] [Indexed: 12/15/2022] Open
Abstract
Background Previous trials have often defined genotype 2 and 3 patients as an “easy to treat” group and guidelines recommend similar management. Aims The present study looks for differences between the two genotypes and analyzes predictive factors for SVR. Methods Prospective, community-based cohort study involving 421 physicians throughout Germany. The analysis includes 2,347 patients with untreated chronic HCV genotype 2 (n = 391) and 3 (n = 1,956) infection treated with PEG-IFN α-2a plus ribavirin between August 2007 and July 2012. Results When compared with genotype 2 patients, those with genotype 3 were younger, had a shorter duration of infection, lower values of total cholesterol, LDL cholesterol and BMI, a higher frequency of drug use as infection mode and male gender (p<0.0001, respectively), and a higher APRI score (p<0.005). SVR was higher in genotype 2 when compared with genotype 3 (64.7% vs. 56.9%, p = 0.004). By multivariate analysis of genotype 2 patients, low baseline γ -GT and RVR predicted SVR. In genotype 3 age ≤45 years, cholesterol>130 mg/dl, a low APRI score, and a γ-GT ≥3-times ULN, RVR, and RBV starting dose were associated with SVR by multivariate analysis. Conclusions The present study corroborates that liver fibrosis is more pronounced in genotype 3 vs. 2. SVR is higher in genotype 2 versus genotype 3 partly because of follow-up problems in genotype 3 patients, in particular in those infected by drug use. Thus, subgroups of genotype 3 patients have adherence problems and need special attention also because they often have significant liver fibrosis. Trial Registration Verband Forschender Arzneimittelhersteller e.V., Berlin, Germany ML21645 ClinicalTrials.gov NCT02106156
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Affiliation(s)
- Claus Niederau
- Clinic for Internal Medicine, St. Josef Hospital, Oberhausen, Germany
- * E-mail:
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Duesseldorf, Germany
| | | | - Albrecht Stoehr
- ifi-Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - Tim Zimmermann
- 1st Medical Clinic, Dept. Gastroenterology and Hepatology, Johannes Gutenberg University of Mainz, Mainz, Germany
| | | | - Gero Moog
- Center of Gastroenterology, Kassel, Germany
| | - Stefan Pape
- Center of Gastroenterology, Paderborn, Germany
| | - Bernd Weber
- Competence Center for Addiction, Praxiszentrum Friedrichsplatz, Kassel, Germany
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Alavi M, Grebely J, Micallef M, Dunlop AJ, Balcomb AC, Day CA, Treloar C, Bath N, Haber PS, Dore GJ. Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study. Clin Infect Dis 2014; 57 Suppl 2:S62-9. [PMID: 23884068 DOI: 10.1093/cid/cit305] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection. METHODS Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia. RESULTS Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64). CONCLUSIONS HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.
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Affiliation(s)
- Maryam Alavi
- The Kirby Institute, University of New South Wales, Sydney, Australia.
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Bruggmann P, Litwin AH. Models of care for the management of hepatitis C virus among people who inject drugs: one size does not fit all. Clin Infect Dis 2014; 57 Suppl 2:S56-61. [PMID: 23884067 DOI: 10.1093/cid/cit271] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Nevertheless, HCV treatment has been delivered successfully to PWID through various multidisciplinary models such as community-based clinics, substance abuse treatment clinics, and specialized hospital-based clinics. Models may be integrated in primary care--all under one roof in either addiction care units or general practitioner-based models--or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management. The impact of highly potent and well-tolerated interferon-free HCV treatment regimens will remain negligible as long as access to therapy cannot be expanded to the most affected risk groups.
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Zeremski M, Zibbell JE, Martinez AD, Kritz S, Smith BD, Talal AH. Hepatitis C virus control among persons who inject drugs requires overcoming barriers to care. World J Gastroenterol 2013; 19:7846-51. [PMID: 24307778 PMCID: PMC3848132 DOI: 10.3748/wjg.v19.i44.7846] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/18/2013] [Accepted: 11/02/2013] [Indexed: 02/06/2023] Open
Abstract
Despite a high prevalence of hepatitis C virus (HCV) infection, the vast majority of persons who inject drugs (PWID) have not engaged in HCV care due to a large number of obstacles. Education about the infection among both PWID and providers remains an important challenge as does discrimination faced by PWID in conventional health care settings. Many providers also remain hesitant to prescribe antiviral therapy due to concerns about adherence and relapse to drug use resulting in reinfection. Presently, however, as a result of improvements in treatment efficacy combined with professional society and government endorsement of HCV treatment for PWID, a pressing need exists to develop strategies to engage these individuals into HCV care. In this article, we propose several strategies that can be pursued in an attempt to engage PWID into HCV management. We advocate that multidisciplinary approaches that utilize health care practitioners from a wide range of specialties, as well as co-localization of medical services, are strategies likely to result in increased numbers of PWID entering into HCV management. Pursuit of HCV therapy after stabilization through drug treatment is an additional strategy likely to increase PWID engagement into HCV care. The full impact of direct acting antivirals for HCV will only be realized if innovative approaches are pursued to engage all HCV infected individuals into treatment.
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Gordon AJ, Bertholet N, McNeely J, Starrels JL, Tetrault JM, Walley AY. 2013 Update in addiction medicine for the generalist. Addict Sci Clin Pract 2013; 8:18. [PMID: 24499640 PMCID: PMC3819258 DOI: 10.1186/1940-0640-8-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/28/2013] [Indexed: 11/10/2022] Open
Abstract
Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles' merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.
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Affiliation(s)
- Adam J Gordon
- VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Joanna L Starrels
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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Afdhal NH, Zeuzem S, Schooley RT, Thomas DL, Ward JW, Litwin AH, Razavi H, Castera L, Poynard T, Muir A, Mehta SH, Dee L, Graham C, Church DR, Talal AH, Sulkowski MS, Jacobson IMFTNPOHCVTMP. The new paradigm of hepatitis C therapy: integration of oral therapies into best practices. J Viral Hepat 2013; 20:745-60. [PMID: 24168254 PMCID: PMC3886291 DOI: 10.1111/jvh.12173] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 08/24/2013] [Indexed: 12/12/2022]
Abstract
Emerging data indicate that all-oral antiviral treatments for chronic hepatitis C virus (HCV) will become a reality in the near future. In replacing interferon-based therapies, all-oral regimens are expected to be more tolerable, more effective, shorter in duration and simpler to administer. Coinciding with new treatment options are novel methodologies for disease screening and staging, which create the possibility of more timely care and treatment. Assessments of histologic damage typically are performed using liver biopsy, yet noninvasive assessments of histologic damage have become the norm in some European countries and are becoming more widespread in the United States. Also in place are new Centers for Disease Control and Prevention (CDC) initiatives to simplify testing, improve provider and patient awareness and expand recommendations for HCV screening beyond risk-based strategies. Issued in 2012, the CDC recommendations aim to increase HCV testing among those with the greatest HCV burden in the United States by recommending one-time testing for all persons born during 1945-1965. In 2013, the United States Preventive Services Task Force adopted similar recommendations for risk-based and birth-cohort-based testing. Taken together, the developments in screening, diagnosis and treatment will likely increase demand for therapy and stimulate a shift in delivery of care related to chronic HCV, with increased involvement of primary care and infectious disease specialists. Yet even in this new era of therapy, barriers to curing patients of HCV will exist. Overcoming such barriers will require novel, integrative strategies and investment of resources at local, regional and national levels.
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Affiliation(s)
- N H Afdhal
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - S Zeuzem
- Department of Medicine, J.W. Goethe University HospitalFrankfurt, Germany
| | - R T Schooley
- Division of Infectious Diseases, San Diego School of Medicine, University of CaliforniaLa Jolla, CA, USA
| | - D L Thomas
- Division of Infectious Diseases, Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - J W Ward
- Division of Viral Hepatitis, Centers for Disease Control and PreventionAtlanta, GA, USA
| | - A H Litwin
- Departments of Medicine and Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of MedicineBronx, NY, USA
| | - H Razavi
- Center for Disease AnalysisLouisville, CO, USA
| | - L Castera
- Service d'Hepatologie, Hopital Beaujon, Assistance Publique Hopitaux de ParisClichy, France
| | - T Poynard
- Service d'Hepatologie, Groupe Hospitalier Pitie-SalpetriereParis, France
| | - A Muir
- Gastroenterology and Hepatology Research Group, Duke Clinical Research InstituteDurham, NC, USA
| | - S H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public HealthBaltimore, MD, USA
| | - L Dee
- Fair Pricing Coalition and AIDS Action BaltimoreBaltimore, MD, USA
| | - C Graham
- Division of Infectious Disease, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - D R Church
- Massachusetts Department of Public Health, Bureau of Infectious DiseaseBoston, MA, USA
| | - A H Talal
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University at BuffaloBuffalo, NY, USA
| | - M S Sulkowski
- Department of Medicine, Johns Hopkins University School of MedicineBaltimore, MD, USA
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Masson CL, Delucchi KL, McKnight C, Hettema J, Khalili M, Min A, Jordan AE, Pepper N, Hall J, Hengl NS, Young C, Shopshire MS, Manuel JK, Coffin L, Hammer H, Shapiro B, Seewald RM, Bodenheimer HC, Sorensen JL, Des Jarlais DC, Perlman DC. A randomized trial of a hepatitis care coordination model in methadone maintenance treatment. Am J Public Health 2013; 103:e81-8. [PMID: 23947319 DOI: 10.2105/ajph.2013.301458] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. METHODS We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. RESULTS Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). CONCLUSIONS Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.
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Affiliation(s)
- Carmen L Masson
- Carmen L. Masson, Kevin L. Delucchi, Jennifer Hettema, Nicole Pepper, Jessica Hall, Nicholas S. Hengl, Michael S. Shopshire, Jennifer K. Manuel, Bradley Shapiro, and James L. Sorensen are with the Department of Psychiatry, Mandana Khalili is with the Department of Medicine, and Hali Hammer is with the Department of Family and Community Medicine, University of California, San Francisco. Courtney McKnight, Albert Min, Ashly E. Jordan, Christopher Young, Lara Coffin, Randy M. Seewald, Henry C. Bodenheimer, Jr, Don C. Des Jarlais, and David C. Perlman are with the Beth Israel Medical Center, New York, NY
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Dimova RB, Zeremski M, Jacobson IM, Hagan H, Des Jarlais DC, Talal AH. Determinants of hepatitis C virus treatment completion and efficacy in drug users assessed by meta-analysis. Clin Infect Dis 2012; 56:806-16. [PMID: 23223596 DOI: 10.1093/cid/cis1007] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV)-infected drug users (DUs) have largely been excluded from HCV care. We conducted a systematic review and meta-analysis of the literature on treatment completion and sustained virologic response (SVR) rates in DUs. We assessed the effects of different treatment approaches and services to promote HCV care among DUs as well as demographic and viral characteristics. METHODS Studies of at least 10 DUs treated with pegylated interferon/ribavirin that reported SVR were analyzed. Heterogeneity was assessed (Cochran test) and investigated (meta-regression), and pooled rates were estimated (random effects). RESULTS Thirty-six studies comprising 2866 patients were retrieved. The treatment completion rate among DUs was 83.4% (95% confidence interval [CI], 77.1%-88.9%). Among studies that included addiction-treated and untreated patients during HCV therapy, the higher the proportion of addiction-treated patients, the higher the HCV treatment completion rate (P < .0001). After adjusting for human immunodeficiency virus (HIV)/HCV coinfection, sex, and treatment of addiction, support services during antiviral therapy increased treatment completion (P < .0001). The pooled SVR rate was 55.5% (95% CI, 50.6%-60.3%). Genotype 1/4 (P = .0012) and the proportion of HIV-coinfected DUs (P = .0173) influenced the SVR rate. After adjusting for HCV genotype 1/4 and HIV/HCV coinfection, the SVR rate was positively correlated with involvement of a multidisciplinary team (P < .0001). CONCLUSIONS Treatment of addiction during HCV therapy results in higher treatment completion. Our pooled SVR rate is similar to that obtained in registration trials in the general population. Treatment of addiction during HCV therapy will likely be important for HCV-infected DUs undergoing treatment with more complex regimens including direct-acting antivirals.
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Jewett A, Smith BD, Garfein RS, Cuevas-Mota J, Teshale EH, Weinbaum CM. Field-based performance of three pre-market rapid hepatitis C virus antibody assays in STAHR (Study to Assess Hepatitis C Risk) among young adults who inject drugs in San Diego, CA. J Clin Virol 2012; 54:213-7. [PMID: 22560051 DOI: 10.1016/j.jcv.2012.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/04/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Approximately 4.1 million Americans are estimated to have been infected with hepatitis C virus (HCV), 45-85% of whom are unaware of their infection. Persons who inject drugs (PWID) account for 55.8% of all persons with HCV antibody (anti-HCV) in the U.S. PWID have limited access to healthcare and are infrequently tested for anti-HCV using conventional laboratory assays. OBJECTIVE To evaluate performance characteristics (sensitivity and specificity) of three, pre-market rapid point-of-care tests (one oral fluid and two finger-stick assays) from two manufacturers (Chembio and MedMira) in settings providing services to young adult PWID in San Diego, CA. STUDY DESIGN Behavioral risk assessment surveys and testing for HCV were conducted among persons who reported injection drug use (IDU) within the past 6 months as part of the Study to Assess Hepatitis C Risk (STAHR) among PWID aged 18-40 years in 2009-2010. Sensitivity and specificity of the rapid anti-HCV assays were evaluated among STAHR participants, using two commonly used testing algorithms. RESULTS Variability in sensitivity (76.6-97.1%) and specificity (99.0-100.0%) was found across assays. The highest sensitivity achieved for the Chembio finger-stick blood, Chembio oral fluid and MedMira finger-stick blood tests was 97.1%, 85.4% and 80.0% respectively; the highest specificity was 99.0%, 100.0% and 100.0%, respectively. In multivariate analysis false negative anti-HCV results were associated with female sex for the MedMira blood assay. CONCLUSIONS Sensitive anti-HCV rapid assays are appropriate and feasible for high-prevalence, high-risk populations such as young PWID.
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Affiliation(s)
- A Jewett
- Oak Ridge Institute for Science and Education, Clinton, TN, USA.
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Talal AH, Dimova RB, Seewald R, Peterson RH, Zeremski M, Perlman DC, Des Jarlais DC. Assessment of methadone clinic staff attitudes toward hepatitis C evaluation and treatment. J Subst Abuse Treat 2012; 44:115-9. [PMID: 22405884 DOI: 10.1016/j.jsat.2012.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 01/17/2012] [Accepted: 01/31/2012] [Indexed: 02/04/2023]
Abstract
We used a 25-item, self-administered questionnaire to assess staff's perceived barriers and willingness to engage in onsite treatment of hepatitis C virus (HCV) at the Beth Israel Medical Center methadone maintenance treatment program (MMTP) at its Harlem sites. Of 80 participants, 50% were counselors and 24% were directly involved in referral or HCV testing. Although 92% of the MMTP staff indicated that they discuss HCV evaluation and treatment with patients at least annually, 70% believed that less than 25% of patients accept referral for HCV treatment and attend their initial appointment. Most staff (66%) supported onsite HCV evaluation and treatment, although support was higher among those with a bachelor's degree or higher (p = 0.046). Lack of infrastructure was perceived as the greatest obstacle to onsite treatment. Educational interventions and skill building for staff to confidently engage and support MMTP patients in HCV treatment may be necessary prerequisites for onsite HCV management in MMTPs.
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Affiliation(s)
- Andrew H Talal
- Center for the Study of Hepatitis C and Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA.
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Bruce RD, Eiserman J, Acosta A, Gote C, Lim JK, Altice FL. Developing a modified directly observed therapy intervention for hepatitis C treatment in a methadone maintenance program: implications for program replication. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 38:206-12. [PMID: 22242700 DOI: 10.3109/00952990.2011.643975] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) is a prevalent chronic blood-borne infection among opioid-dependent patients on methadone maintenance treatment (MMT). Despite case reports and case-control studies, a randomized controlled trial (RCT) examining HCV treatment adherence in methadone-maintained patients is lacking and was the impetus for this ongoing RCT examining modified directly administered therapy for HCV treatment integrated within a MMT. METHODS Subjects were randomized 1:1 to receive HCV treatment as modified directly observed therapy (mDOT) into the MMT program or at a liver specialty clinic as self-administered therapy (SAT). Randomization was stratified based on HIV status and HCV genotype. RESULTS Twenty-one subjects to date have enrolled in this pilot study. The mDOT subjects have had greater success in starting treatment and 10 of the 12 mDOT subjects achieved early virologic response (EVR) at week 12 and 6 of those 10 achieved sustained virologic response (SVR). Of the nine SAT subjects, only three achieved EVR at week 12 and only one achieved SVR despite not completing the treatment. CONCLUSIONS Hepatitis C treatment can be successfully integrated into a methadone maintenance clinic, and mDOT can be implemented with a methadone clinic's existing nursing and medical staff. Patients struggling with concurrent substance use and mental illness comorbidity may be successfully addressed in such settings and facilitate access to and completion of treatment through the utilization of on-site clinical services for HCV treatment and adherence support with mDOT. The exact importance of site of services and adherence support remains a significant area for future investigation.
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