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Zovich B, Freeland C, Moore H, Sapp K, Qureshi A, Holbert R, Zambrano J, Bhangoo D, Cohen C, Hass RW, Jessop A. Dismantling Barriers to Hepatitis B and Delta Screening, Prevention, and Linkage to Care among the PWUD Community in Philadelphia. Viruses 2024; 16:628. [PMID: 38675969 PMCID: PMC11054430 DOI: 10.3390/v16040628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
The prevalence of hepatitis B and delta viruses (HBV/HDV) among people who use drugs (PWUD) remains largely unknown. In the context of one Philadelphia-based harm reduction organization (HRO), this study aimed to assess HBV/HDV prevalence and facilitate linkage to care. Participants completed a demographic HBV/HDV risk factor survey and were screened for HBV and reflexively for HDV if positive for HBV surface antigen or isolated core antibody. Fisher's exact tests and regression were used to understand relationships between risks and HBV blood markers. Of the 498 participants, 126 (25.3%) did not have hepatitis B immunity, 52.6% had been vaccinated against HBV, and 17.9% had recovered from a past infection. Eleven (2.2%) participants tested positive for isolated HBV core antibody, 10 (2.0%) for HBV surface antigen, and one (0.2%) for HDV antibody. History of incarceration was associated with current HBV infection, while transactional sex and experience of homelessness were predictive of previous exposure. This study found high rates of current and past HBV infection, and a 10% HBV/HDV co-infection rate. Despite availability of vaccine, one quarter of participants remained vulnerable to infection. Findings demonstrate the need to improve low-threshold HBV/HDV screening, vaccination, and linkage to care among PWUD. The study also identified gaps in the HBV/HDV care cascade, including lack of point-of-care diagnostics and lack of support for HROs to provide HBV services.
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Affiliation(s)
| | | | - Holly Moore
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | - Kara Sapp
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | | | - Rachel Holbert
- HepTREC at Prevention Point Philadelphia, Philadelphia, PA 19134, USA
| | | | - Daljinder Bhangoo
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Chari Cohen
- Hepatitis B Foundation, Doylestown, PA 18902, USA
| | - Richard W. Hass
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Amy Jessop
- HepTREC at Prevention Point Philadelphia, Philadelphia, PA 19134, USA
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2
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Parker R, Allison M, Anderson S, Aspinall R, Bardell S, Bains V, Buchanan R, Corless L, Davidson I, Dundas P, Fernandez J, Forrest E, Forster E, Freshwater D, Gailer R, Goldin R, Hebditch V, Hood S, Jones A, Lavers V, Lindsay D, Maurice J, McDonagh J, Morgan S, Nurun T, Oldroyd C, Oxley E, Pannifex S, Parsons G, Phillips T, Rainford N, Rajoriya N, Richardson P, Ryan J, Sayer J, Smith M, Srivastava A, Stennett E, Towey J, Vaziri R, Webzell I, Wellstead A, Dhanda A, Masson S. Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group. BMJ Open Gastroenterol 2023; 10:e001221. [PMID: 37797967 PMCID: PMC10551993 DOI: 10.1136/bmjgast-2023-001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care. DESIGN A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives. RESULTS The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided. CONCLUSION It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.
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Affiliation(s)
- Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, UK
| | | | - Seonaid Anderson
- Angus Integrated Drug and Alcohol Recovery Service (AIDARS), Ninewells Hospital and Medical School, Dundee, UK
| | - Richard Aspinall
- Gastroenterology & Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Sara Bardell
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vikram Bains
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Ryan Buchanan
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lynsey Corless
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ian Davidson
- NHS Fife Addiction Services, NHS Fife, Kirkcaldy, UK
| | - Pauline Dundas
- Peter Brunt Centre, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Jeff Fernandez
- Alcohol and Drug Liaison, Royal Free London NHS Foundation Trust, London, UK
| | - Ewan Forrest
- Dept of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Erica Forster
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Dennis Freshwater
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ruth Gailer
- Islington Primary Care Federation, London, UK
| | - Robert Goldin
- Department of Digestive Diseases, Department of Medicine, Imperial College London, London, UK
| | | | - Steve Hood
- Digestive Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Arron Jones
- Pharmacy, Barts and The London NHS Trust, London, UK
| | | | - Deborah Lindsay
- Alcohol Care Team, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - James Maurice
- Gastroenterology and hepatology, North Bristol NHS Trust, Westbury on Trym, UK
| | - Joanne McDonagh
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Tania Nurun
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | - Sally Pannifex
- Hepatology, St George's Healthcare NHS Trust, London, UK
| | | | | | - Nicole Rainford
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Neil Rajoriya
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Richardson
- Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - J Ryan
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Joanne Sayer
- Gastroenterology, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | - Mandy Smith
- Alcohol care team, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Ankur Srivastava
- Gastroenterology and hepatology, North Bristol NHS Trust, Westbury on Trym, UK
| | - Emma Stennett
- Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Jennifer Towey
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Ian Webzell
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew Wellstead
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Ashwin Dhanda
- Faculty of health, University of Plymouth, Plymouth, UK
| | - Steven Masson
- Liver unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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3
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Balsom CR, Farrell A, Kelly DV. Barriers and enablers to testing for hepatitis C virus infection in people who inject drugs - a scoping review of the qualitative evidence. BMC Public Health 2023; 23:1038. [PMID: 37259073 DOI: 10.1186/s12889-023-16017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Injection drug use is the primary mode of transmission of hepatitis C virus (HCV) infection in the developed world and guidelines recommend screening individuals with current or history of injection drug use for HCV; however, the majority of those living with HCV in Canada are not aware of their positive status. This low level of HCV status awareness suggests that screening is not effective with current testing strategies. The aim of this review is to determine what barriers and enablers people who inject drugs (PWID) experience surrounding testing for HCV to help inform the development of an engaging testing strategy. METHODS Comprehensive literature searches were conducted using Medline, Embase and CINAHL in February 2021. Included studies investigated the barriers and enablers to testing for HCV in PWID and the experiences of PWID in testing for HCV. Studies were included if they were qualitative or mixed-methods design, involved people with current injection drug use or those with a history of injecting drugs, and were written in the English language. Studies were compared and common themes were coded and analyzed. RESULTS The literature search resulted in 1554 citations and ultimately nine studies were included. Common barriers included self-perception of low risk for HCV, fear of diagnosis, stigma associated with IV drug use and HCV, antipathy in relation to mainstream health care services, limited knowledge about HCV, lack of rapport with provider, lack of motivation or competing priority of drug use, and limited awareness of new treatment options. Common enablers to testing included increasing awareness of HCV testing and treatment and providing positive narratives around HCV care, positive rapport with provider, accessible testing options and individualized care. CONCLUSION While there has been some qualitative research on barriers and enablers to testing for HCV in PWID more research is needed to focus on this research question as a primary objective in order to provide more understanding from the participant's perspective.
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Affiliation(s)
- Cathy R Balsom
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Canada.
| | - Alison Farrell
- Health Sciences Library, Memorial University of Newfoundland, St. John's, Canada
| | - Deborah V Kelly
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Canada
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Bryce K, Smith C, Rodger A, Macdonald D. Falling treatment uptake in the hepatitis C care cascade is a growing threat to achieving elimination. J Viral Hepat 2023; 30:46-55. [PMID: 36197840 PMCID: PMC10091771 DOI: 10.1111/jvh.13757] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 12/13/2022]
Abstract
Most high-income countries are not on track to achieve the World Health Organization hepatitis C elimination targets. As elimination programmes assess growing proportions of patients in community-based pathways, rates of treatment uptake may fall. We aimed to identify factors associated with DAA treatment uptake and measure changes in their prevalence over time. We performed a time-to-treatment analysis on 2728 patients approved for hepatitis C Direct-Acting Antiviral treatment in the North Central London region between January 2016 and October 2019. We investigated the association between treatment uptake and factors including assessment/treatment setting (hospital, drug service or prison), patient age, gender, injection drug use, harmful alcohol use, cirrhosis status and previous treatment. The likelihood of treatment uptake was reduced by three independent risk factors. These included assessment setting: prison-based or drug-service pathways (aHR 0.29 or 0.81 vs. hospital outpatient pathway, 95% CI 0.21-0.40 and 0.70-0.94 respectively, p < .001); being UK-born (aHR 0.89 vs. non-UK born, 0.82-0.98, p = .01); and history of harmful alcohol use (aHR 0.84 vs. no history, 0.72-0.99, p = .04). The average number of these risk factors for not starting treatment per patient increased over time (R2 = 0.66 p < .001). Independent of these, there was an additional 5% reduction in rate of treatment initiation in each successive year of the programme (aHR 0.95, 0.91-0.99, p = .02). In conclusion, disengagement from care before treatment uptake was found to be a growing threat to elimination. Despite provision of community-based test-to-cure pathways, there are persistent barriers to treatment uptake and these are increasing over time.
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Affiliation(s)
- Kathleen Bryce
- Institute for Global HealthUniversity College LondonLondonUK
- Royal Free London NHS Foundation TrustLondonUK
| | - Colette Smith
- Institute for Global HealthUniversity College LondonLondonUK
| | - Alison Rodger
- Institute for Global HealthUniversity College LondonLondonUK
- Royal Free London NHS Foundation TrustLondonUK
| | - Douglas Macdonald
- Royal Free London NHS Foundation TrustLondonUK
- Institute for Liver and Digestive HealthUniversity College LondonLondonUK
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5
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Howell J, Traeger MW, Williams B, Layton C, Doyle JS, Latham N, Draper B, Bramwell F, Membrey D, McPherson M, Roney J, Stoové M, Thompson AJ, Hellard ME, Pedrana A. The impact of point-of-care hepatitis C testing in needle and syringe exchange programs on linkage to care and treatment uptake among people who inject drugs: An Australian pilot study. J Viral Hepat 2022; 29:375-384. [PMID: 35274403 DOI: 10.1111/jvh.13664] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/20/2022] [Indexed: 12/13/2022]
Abstract
Point-of-care (POC) diagnostics overcome barriers to conventional hepatitis C (HCV) testing in people who inject drugs. This study assessed impact on hepatitis C treatment uptake of POC HCV testing in needle and syringe exchange programs (NSPs). Rapid EC was a single-arm interventional pilot study of HCV POC testing conducted in three inner-city community clinics with NSPs. Twelve months after the POC testing, a retrospective medical record and Pharmaceutical Benefits Scheme audit was performed to determine the number of HCV RNA-positive participants who were prescribed HCV treatment. 70 HCV RNA-positive Rapid EC study participants were included. 44 (63%) were prescribed DAAs; 26 (59%) completed treatment and 15 (34%) had SVR testing, all of whom were cured. Age ≥ 40 years (aOR 3.45, 95% CI 1.10-11.05, p = .03) and secondary school education (aOR 5.8, 95% CI 1.54-21.80, p = .009) had higher likelihood of being prescribed DAAs, whereas homelessness was inversely associated with prescription of DAAs (aOR 0.30, 95% CI 0.09-1.04, p = .057). Median time to receive a DAA script from date of diagnosis was seven days (IQR 0 to 14 days), and time to filling the DAA prescription was 2 days (IQR 0-12 days). In conclusion, provision of POC testing through NSPs was effective for linking new clients to HCV treatment and reduced the time to treatment. Further studies are needed to define the most cost-effective use of POC testing in models of care for people who inject drugs to increase HCV treatment uptake.
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Affiliation(s)
- Jessica Howell
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Traeger
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bridget Williams
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Chloe Layton
- Cohealth, General Practice, Melbourne, Victoria, Australia
| | - Joseph S Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Alfred and Monash University, Melbourne, Victoria, Australia
| | - Ned Latham
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Bridget Draper
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Dean Membrey
- Cohealth, General Practice, Melbourne, Victoria, Australia
| | - Maggie McPherson
- North Richmond Community Health, General Practice, Melbourne, Victoria, Australia
| | - Janine Roney
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
| | - Mark Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Alexander J Thompson
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret E Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Cohealth, General Practice, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia.,Doherty Institute and School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alisa Pedrana
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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6
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Grebely J, Collins AB, Artenie AA, Sutherland R, Meyer JP, Barocas JA, Falade-Nwulia O, Cepeda JA, Cunningham EB, Hajarizadeh B, Lafferty L, Lazarus JV, Bonn M, Marshall AD, Treloar C. Progress and remaining challenges to address hepatitis C, other infectious diseases, and drug-related harms to improve the health of people who use drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 96:103469. [PMID: 34610884 DOI: 10.1016/j.drugpo.2021.103469] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | | | | | - Rachel Sutherland
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Jaimie P Meyer
- AIDS Program, Yale School of Medicine, New Haven, United States; Chronic Disease Epidemiology, Yale School of Public Health, New Haven, United States
| | - Joshua A Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado School of Medicine, Aurora, United States
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Javier A Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health,Baltimore, United States
| | | | | | - Lise Lafferty
- The Kirby Institute, UNSW Sydney, Sydney, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Matthew Bonn
- Canadian Association of People Who Use Drugs, Dartmouth, Canada
| | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, Australia; Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia
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7
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Exploring and understanding HCV patient journeys- HEPCARE Europe project. BMC Infect Dis 2021; 21:239. [PMID: 33673828 PMCID: PMC7934512 DOI: 10.1186/s12879-021-05928-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background Hepatitis C Virus (HCV) is a leading cause for chronic liver diseases worldwide. The European Union and World Health Organization aspire to eliminate HCV by 2030. However, among at-risk populations, including, homeless people, prisoners and People Who Inject Drugs, access to diagnosis and treatment is challenging. Hepcare Europe is an integrated model of care developed to address this by assessing potential reasons for these restrictions and determining measures needed to improve HCV diagnosis, treatment and access to care within different communities. Objectives HepCare Europe is an EU-supported project involving collaboration between five institutions in: Ireland, United Kingdom, Spain and Romania. We aim to explore the journey of care experienced by those living with HCV with a focus on previous care disruptions (loss to follow up) and the new HepCare Europe Programme. Methods Research teams conducted semi-structured interviews with patients who accessed services through HepCare Europe thus, patients were recruited by purposeful sampling. Patients interviewed had received, or were in the final weeks of receiving, treatment. The interviews were audio recorded, transcribed and translated into English, and sent to the Dublin team for inductive thematic analysis. Researchers from the HepCare Europe research team coded the data separately, then together. Results Common themes are introduced to present similarities, following individual site themes to highlight the importance of tailored interventions for each country. Key themes are: 1) Hepatitis C patients lost to follow up 2) HepCare improved access to treatment and 3) the need for improved HCV education. Individual themes also emerged for each site. These are: Ireland: New opportunities associated with achieving Sustained Virologic Responses (SVR). Romania: HCV is comparatively less crucial in light of Human Immunodeficiency Viruses (HIV) coinfections. UK: Patients desire support to overcome social barriers and Spain: Improved awareness of HCV, treatment and alcohol use. Conclusion This study identified how the tailored HepCare interventions enabled improved HCV testing and linkage to care outcomes for these patients. Tailored interventions that targeted the needs of patients, increased the acceptability and success of treatment by patients. HepCare demonstrated the need for flexibility in treatment delivery, and provided additional supports to keep patients engaged and educated on new treatment therapies.
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8
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Morris L, Selvey L, Williams O, Gilks C, Smirnov A. Reasons for Not Seeking Hepatitis C Treatment among People Who Inject Drugs. Subst Use Misuse 2021; 56:175-184. [PMID: 33208025 DOI: 10.1080/10826084.2020.1846198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Despite increases in treatment uptake for hepatitis C viral infection (HCV) in Australia since the introduction of direct acting antiviral (DAA) therapy, a large proportion of HCV-infected people who inject drugs (PWID) have not sought treatment. Purpose/Objectives: To examine predictors of treatment uptake and reasons for not seeking treatment among PWID. Methods: PWID (n = 404) recruited through five needle and syringe programs in South East Queensland were interviewed about HCV testing, status and treatment, recent injecting drug use, mental health and reasons for not taking up treatment. Predictors of treatment uptake were examined using unadjusted and adjusted logistic regression analyses. Proportions were calculated for participants reporting each reason for not taking up treatment. Results: We recruited 404 PWID. Of those tested for HCV (94%), 55% were HCV antibody positive and 31% with active infection. Approximately 36% of eligible participants had begun or completed DAA treatment. In adjusted analyses, injecting drugs three or more times per day was associated with not taking up HCV treatment (p = 0.005). Common reasons for not seeking treatment ("applied a lot") included experiencing no HCV-related symptoms (25%), HCV treatment not being a priority (23%), fear of treatment side effects (18%), and no knowledge of DAA treatments (15%). Conclusions/Importance: HCV education efforts for PWID should target misperceptions and lack of awareness of DAA therapy, and highlight the likely benefits of treatment even when asymptomatic. The use of peer workers and increased investment in integrated treatment facilities will likely aid treatment uptake.
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Affiliation(s)
- Leith Morris
- School of Public Health, The University of Queensland, Herston, Australia
| | - Linda Selvey
- School of Public Health, The University of Queensland, Herston, Australia
| | - Owain Williams
- School of Public Health, The University of Queensland, Herston, Australia
| | - Charles Gilks
- School of Public Health, The University of Queensland, Herston, Australia
| | - Andrew Smirnov
- School of Public Health, The University of Queensland, Herston, Australia.,Queensland Alcohol and Drug Research and Education Centre, The University of Queensland, Herston, Australia
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9
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Goutzamanis S, Doyle JS, Horyniak D, Higgs P, Hellard M. Peer to peer communication about hepatitis C treatment amongst people who inject drugs: A longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102983. [PMID: 33126166 DOI: 10.1016/j.drugpo.2020.102983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little is known about how information on direct-acting antiviral treatment for hepatitis C circulates through peer networks of people who inject drugs. In this study we aimed to explore what and how treatment-related information is shared between people undergoing treatment and their peers. METHODS Participants were recruited from two general practice clinics and the community-based hepatitis C Treatment and Prevention Study. Semi-structured interviews were conducted with each participant (N = 20) before, during and following treatment. Interviews explored hepatitis C treatment experiences, key sources of DAA information and the impact of receiving and sharing knowledge. Inductive thematic analysis was conducted. Time sequential matrices were generated to understand thematic change over time. RESULTS Fifty-four interviews were conducted with 20 participants across seven field-sites in Melbourne, Australia. Key themes were: 'peers as a source treatment information', 'do it together' and 'becoming a treatment advocate'. Peers were a crucial trusted source of information. Positive treatment anecdotes were important for building confidence in and motivation to initiate treatment. Many participants adopted a 'treatment advocate' role in their close peer networks, which was described as empowering. Some participants described benefits of undertaking treatment alongside members of their close network. CONCLUSION Findings illustrate the importance of close peers in shaping treatment perceptions and engagement. This will be important in designing health promotion messaging and interventions to increase treatment uptake.
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Affiliation(s)
- Stelliana Goutzamanis
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, SA, 3004; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne VIC 3004.
| | - Joseph S Doyle
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, SA, 3004; Department of Infectious Diseases, The Alfred and Monash University, 85 Commercial Rd, Melbourne, Victoria, SA, 3004
| | - Danielle Horyniak
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, SA, 3004; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne VIC 3004; Behaviour and Health Risks Program, Burnet Institute, 85 Commercial Rd, Melbourne, Victoria, SA, 3004
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, SA, 3004; Department of Public Health, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora VIC 3086
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, 85 Commercial Rd, Melbourne, VIC, SA, 3004; School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne VIC 3004; Department of Infectious Diseases, The Alfred and Monash University, 85 Commercial Rd, Melbourne, Victoria, SA, 3004
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10
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Sherbuk JE, Tabackman A, McManus KA, Kemp Knick T, Schexnayder J, Flickinger TE, Dillingham R. A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South. Harm Reduct J 2020; 17:64. [PMID: 32948189 PMCID: PMC7501689 DOI: 10.1186/s12954-020-00409-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/26/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States. METHODS We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care. RESULTS Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care. CONCLUSIONS Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.
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Affiliation(s)
- Jacqueline E Sherbuk
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA.
| | - Alexa Tabackman
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kathleen A McManus
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Terry Kemp Knick
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Julie Schexnayder
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Tabor E Flickinger
- Division of General, Geriatric, Palliative, and Hospital Medicine, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Rebecca Dillingham
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
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11
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Biondi MJ, Feld JJ. Hepatitis C models of care: approaches to elimination. CANADIAN LIVER JOURNAL 2020; 3:165-176. [PMID: 35991853 PMCID: PMC9202783 DOI: 10.3138/canlivj.2019-0002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 07/29/2023]
Abstract
Hepatitis C direct-acting antivirals (DAAs) have an efficacy of 95% or greater, with pangenotypic options. Many regions in Canada have recently abolished the need to demonstrate fibrosis before treatment with DAAs, and several combination therapies are available under public and private insurance coverage. As a result, efforts to increase treatment are largely focused on engaging specific populations and providers. With minimal side effects and decreased need for monitoring, hepatitis C screening, linkage, and treatment can largely be done in a single setting. In this article, we highlight both Canadian and international examples of the specialist's ongoing role and discuss the task shifting of hepatitis C treatment to primary care; specialized community clinics; and mental health, corrections, addictions, and opioid substitution therapy settings. Although specialists continue to support most models of care described in the literature, we highlight the potential for non-specialist care in working toward the elimination of hepatitis C in Canada.
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Affiliation(s)
- Mia J Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario
- Arthur Labatt Family School of Nursing, Western University, London, Ontario
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario
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12
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Biondi MJ, Feld JJ. Hepatitis C models of care: approaches to elimination. CANADIAN LIVER JOURNAL 2020. [DOI: 10.3138/canlivj-2019-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hepatitis C direct-acting antivirals (DAAs) have an efficacy of 95% or greater, with pangenotypic options. Many regions in Canada have recently abolished the need to demonstrate fibrosis before treatment with DAAs, and several combination therapies are available under public and private insurance coverage. As a result, efforts to increase treatment are largely focused on engaging specific populations and providers. With minimal side effects and decreased need for monitoring, hepatitis C screening, linkage, and treatment can largely be done in a single setting. In this article, we highlight both Canadian and international examples of the specialist’s ongoing role and discuss the task shifting of hepatitis C treatment to primary care; specialized community clinics; and mental health, corrections, addictions, and opioid substitution therapy settings. Although specialists continue to support most models of care described in the literature, we highlight the potential for non-specialist care in working toward the elimination of hepatitis C in Canada.
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Affiliation(s)
- Mia J Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario
- Arthur Labatt Family School of Nursing, Western University, London, Ontario
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario
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13
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Grebely J, Read P, Cunningham EB, Weltman M, Matthews GV, Dunlop A, Montebello M, Martinello M, Gilliver R, Marks P, Applegate TL, Dore GJ. Elbasvir and grazoprevir for hepatitis C virus genotype 1 infection in people with recent injecting drug use (DARLO-C): An open-label, single-arm, phase 4, multicentre trial. Health Sci Rep 2020; 3:e151. [PMID: 32270056 PMCID: PMC7136479 DOI: 10.1002/hsr2.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/15/2020] [Accepted: 02/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND AIMS Direct-acting antiviral therapy for hepatitis C virus (HCV) is effective, but few prospective studies among people with ongoing injecting drug use exist. This study evaluated the efficacy of elbasvir/grazoprevir in people with HCV genotype 1/4 (G1/4) infection and recent injecting drug use. An exploratory aim evaluated the feasibility of fingerstick point-of-care HCV RNA testing prior to and following treatment. METHODS DARLO-C (http://clinicaltrials.gov: NCT02940691) is an open-label phase 4 trial. Participants were recruited between May 2017 and March 2018 from two drug treatment clinics, two hospital clinics, and one community clinic in Australia. Inclusion criteria included recent injection drug use (previous 6 months) and HCV G1/4 infection. Exclusion criteria included prior HCV treatment and decompensated liver disease. Participants received elbasvir/grazoprevir once-daily for 12 weeks. The primary endpoint was undetectable HCV RNA 12 weeks post-treatment (SVR). Fingerstick whole-blood samples were tested using the Xpert HCV Viral Load Fingerstick (Xpert HCV VL Fingerstick) assay and compared to the Aptima HCV Quant Dx Assay on plasma samples. RESULTS Of a planned 150 participants, 32 were enrolled due to slower than anticipated recruitment [median age 46 years, 10 (31%) female, 29 (91%) G1a]. Eighteen (56%) were receiving opioid agonist therapy and 29 (91%) injected in the previous month. Twenty-six (81%) of 32 completed treatment (lost to follow-up, n = 5; incarceration, n = 1). There were no virological failures. Twenty-four (75%, 95% CI 59%-91%) of 32 achieved SVR. Two participants who completed treatment did not have SVR (loss to follow-up, n = 1; refused test, n = 1). Among paired samples (n = 36), sensitivity of the Xpert HCV VL Fingerstick assay for HCV RNA detection was 100.0% (95% CI 75.3%-100.0%) and specificity was 95.7% (95% CI 78.1%-99.9%). CONCLUSION Elbasvir/grazoprevir is effective among people with HCV G1 with recent injecting drug use. Implementation of point-of-care HCV RNA testing was feasible, but the high error rate requires investigation.
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Affiliation(s)
- Jason Grebely
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
| | | | - Evan B. Cunningham
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
| | - Martin Weltman
- Department of Gastroenterology and HepatologyNepean HospitalPenrithAustralia
| | - Gail V. Matthews
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
- Department of Infectious DiseasesSt Vincent's HospitalSydneyAustralia
| | | | - Mark Montebello
- Drug and Alcohol ServicesSouth East Sydney Local Health DistrictSydneyAustralia
| | - Marianne Martinello
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
- Department of Infectious DiseasesSt Vincent's HospitalSydneyAustralia
| | | | - Philippa Marks
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
| | - Tanya L. Applegate
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
| | - Gregory J. Dore
- Viral Hepatitis Clinical Research ProgramThe Kirby Institute, UNSW SydneySydneyAustralia
- Department of Infectious DiseasesSt Vincent's HospitalSydneyAustralia
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14
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Goodyear T, Ti L, Carrieri P, Small W, Knight R. "Everybody living with a chronic disease is entitled to be cured": Challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 81:102766. [PMID: 32416525 DOI: 10.1016/j.drugpo.2020.102766] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent advances in the safety, tolerability, and efficacy of hepatitis C virus (HCV) treatments have led to the introduction of policy changes that include, in some settings, universal coverage of direct-acting antiviral (DAA) treatment for people living with HCV. However, people who inject drugs (PWID), a population with disproportionately high rates of HCV, often experience significant social and structural barriers to care, including when seeking treatment and care for blood-borne viruses. The objective of this study is to identify implementation challenges and opportunities for improving HCV-related care and scaling up DAA treatment for PWID living with HCV in a setting with universal DAA coverage since 2018. METHODS Informed by a critical interpretive framework, this study thematically analyzes data from in-depth, semi-structured interviews conducted between October 2018 and February 2019 with a purposive sample of 15 expert stakeholders (e.g., clinicians, community-based organization representatives, policy makers) related to HCV care or research in British Columbia, Canada. RESULTS Our analysis revealed two key thematics: First, participants described existing challenges for scaling up DAA treatment, including how contextual factors (e.g., housing, stigma) restrict opportunities for PWID to engage in care. Participants also described how strained and compartmentalized health services are onerous to navigate for patients. Second, participants described opportunities for improving HCV-related care through various structural interventions (e.g., improved housing, decriminalization of substance use), and enhanced and more accessible models of care (e.g., decentralized, integrated, outreach-focused, and peer- and nurse-led services). CONCLUSIONS These findings emphasize that several key service delivery and system-level adaptations are required in order to equitably scale up access of DAAs to PWID living with HCV, including policies and programs that are responsive to socio-structural determinants of health.
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Affiliation(s)
- Trevor Goodyear
- British Columbia Centre on Substance Use, Vancouver, Canada; School of Nursing, University of British Columbia, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Patrizia Carrieri
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Économiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, Canada; Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada.
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15
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Bajis S, Grebely J, Hajarizadeh B, Applegate T, Marshall AD, Ellen Harrod M, Byrne J, Bath N, Read P, Edwards M, Gorton C, Hayllar J, Cock V, Peterson S, Thomson C, Weltman M, Jefferies M, Wood W, Haber P, Ezard N, Martinello M, Maher L, Dore GJ. Hepatitis C virus testing, liver disease assessment and treatment uptake among people who inject drugs pre- and post-universal access to direct-acting antiviral treatment in Australia: The LiveRLife study. J Viral Hepat 2020; 27:281-293. [PMID: 31698545 DOI: 10.1111/jvh.13233] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/04/2019] [Accepted: 10/07/2019] [Indexed: 02/06/2023]
Abstract
Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided fingerstick whole-blood samples for dried blood spot, Xpert HCV Viral Load and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n = 550), 64% (n = 537) injected drugs in the previous month, and 67% (n = 560) reported currently receiving opioid substitution therapy. Overall, 45% (n = 380) had detectable HCV RNA, of whom 23% (n = 86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.
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Affiliation(s)
- Sahar Bajis
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | | | - Alison D Marshall
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Jude Byrne
- Australian Injecting and Illicit Drug Users League, Canberra, ACT, Australia
| | - Nicky Bath
- NSW Users and AIDS Association, Sydney, NSW, Australia
| | | | - Michael Edwards
- South Western Sydney Local Health District Drug Health Services, Sydney, NSW, Australia
| | - Carla Gorton
- Cairns Sexual Health Service, Cairns, QLD, Australia
| | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Victoria Cock
- Drug and Alcohol Services of South Australia, Adelaide, SA, Australia
| | | | - Claire Thomson
- Bayside Alcohol and Drug Services, Cleveland, QLD, Australia
| | | | | | - William Wood
- Sydney Medically Supervised Injecting Centre, Sydney, NSW, Australia
| | - Paul Haber
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nadine Ezard
- Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | | | - Lisa Maher
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,Burnet Institute, Melbourne, Vic, Australia
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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16
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Lim AG, Walker JG, Mafirakureva N, Khalid GG, Qureshi H, Mahmood H, Trickey A, Fraser H, Aslam K, Falq G, Fortas C, Zahid H, Naveed A, Auat R, Saeed Q, Davies CF, Mukandavire C, Glass N, Maman D, Martin NK, Hickman M, May MT, Hamid S, Loarec A, Averhoff F, Vickerman P. Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis. Lancet Glob Health 2020; 8:e440-e450. [PMID: 32087176 PMCID: PMC7295205 DOI: 10.1016/s2214-109x(20)30003-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/07/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence. METHODS We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018-30. We calibrated the model to country-level demographic data for 1960-2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007-08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs. FINDINGS One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13·8 million (95% UI 13·4-14·1) individuals being screened and 350 000 (315 000-385 000) treatments started annually, decreasing hepatitis C incidence by 26·5% (22·5-30·7) over 2018-30. Prioritised screening of high prevalence groups (PWID and adults aged ≥30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46·8% and decrease incidence by 50·8% (95% UI 46·1-55·0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US$8·1 billion, reducing to $3·9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm. INTERPRETATION Pakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030. FUNDING UNITAID.
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Affiliation(s)
- Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Josephine G Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Hassan Mahmood
- Pakistan Health Research Council, Islamabad, Pakistan; WHO, Islamabad, Pakistan
| | - Adam Trickey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | | | - Ammara Naveed
- Department of Gastroenterology and Hepatology, Pakistan Kidney and Liver Institute and Research Center, Lahore, Pakistan
| | - Rosa Auat
- Médecins Sans Frontières, Brussels, Belgium
| | - Quaid Saeed
- National AIDS Control Programme, Islamabad, Pakistan
| | - Charlotte F Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Nancy Glass
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David Maman
- Epicentre, Médecins Sans Frontières, Paris, France
| | - Natasha K Martin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, CA, USA
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Margaret T May
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Anne Loarec
- Epicentre, Médecins Sans Frontières, Paris, France
| | - Francisco Averhoff
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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17
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Phillips C, Schulkind J, O'Sullivan M, Edelman N, Smith HE, Verma S, Jones CJ. Improving access to care for people who inject drugs: Qualitative evaluation of project ITTREAT-An integrated community hepatitis C service. J Viral Hepat 2020; 27:176-187. [PMID: 31566851 DOI: 10.1111/jvh.13214] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/08/2019] [Accepted: 08/31/2019] [Indexed: 12/11/2022]
Abstract
Achieving hepatitis C virus (HCV) elimination by 2030 requires an increased linkage to care for people who inject drugs (PWID). Project ITTREAT was established to mitigate barriers to HCV care by providing an integrated service within a local drug and alcohol treatment centre. This study aimed to explore the experiences of clients and staff involved in Project ITTREAT and assess the facilitators and barriers to a community-based HCV service. Between October 2014 and April 2016, drug and alcohol treatment attendees were interviewed using one-to-one semi-structured interviews. Drug and alcohol treatment staff took part in focus groups. All data were recorded, transcribed verbatim and analysed using thematic content analysis. Fifteen drug and alcohol treatment attendees with current/previous HCV infection were interviewed, and 15 staff members contributed across two focus groups. Drug and alcohol treatment staff and attendees reported that Project ITTREAT facilitated access to HCV care by mitigating previous negative hospital-based experiences. Other key facilitators were positive narratives around HCV care, and drug and alcohol treatment attendees being well engaged in their drug/alcohol recovery. Barriers included a lack of stability in drug and alcohol treatment attendees, negative discourse around testing/treatment and stigma associated with attending the drug and alcohol treatment to access HCV treatment in some who had successfully achieved drug rehabilitation. Our findings indicate the positive impact of an integrated and personalized community-based service delivered by a dedicated hepatitis nurse. This played a crucial role in reducing barriers to HCV care for PWID. Our work also highlights areas for future investment including non-DAT-based community services and increasing awareness of new treatments amongst this cohort.
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Affiliation(s)
- Clare Phillips
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - Jasmine Schulkind
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Margaret O'Sullivan
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK
| | - Natalie Edelman
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, Brighton, UK
| | - Helen E Smith
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, Brighton, UK.,Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Sumita Verma
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital NHS Trust, Brighton, UK.,Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
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18
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Litwin AH, Drolet M, Nwankwo C, Torrens M, Kastelic A, Walcher S, Somaini L, Mulvihill E, Ertl J, Grebely J. Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: The C-SCOPE Study. J Viral Hepat 2019; 26:1094-1104. [PMID: 31074167 PMCID: PMC6771477 DOI: 10.1111/jvh.13119] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/18/2019] [Accepted: 04/09/2019] [Indexed: 12/15/2022]
Abstract
The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians practicing in clinics offering opioid agonist treatment (OAT). C-SCOPE was a study consisting of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe and the United States between April and May 2017. A 5-point Likert scale (1 = not a barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to perceived barriers for HCV testing, evaluation and treatment across the domains of the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor access to on-site venepuncture (35%), point-of-care HCV testing (16%), and noninvasive liver disease assessment (25%). Only 30% of OAT physicians reported personally treating HCV infection. Major perceived health system barriers to HCV management included the lack of funding for noninvasive liver disease testing, long wait times to see an HCV specialist, lack of funding for new HCV therapies, and reimbursement restrictions based on drug/alcohol use. Major perceived clinic barriers included the lack of peer support programmes and/or HCV case managers to facilitate linkage to care, the need to refer people off-site for noninvasive liver disease staging, the lack of support for on-site phlebotomy and the lack of on-site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics.
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Affiliation(s)
- Alain H. Litwin
- Department of MedicineUniversity of South Carolina School of Medicine ‐ Greenville and Prisma HealthGreenvilleSouth Carolina,Clemson University School of Health ResearchClemsonSouth Carolina
| | | | | | - Martha Torrens
- Department of PsychiatryInstitut de Neuropsiquiatria i AddiccionsHospital del Mar BarcelonaIMIM (Institut Hospital del Mar d'Investigacions Mediques)Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Andrej Kastelic
- National Centre for the Treatment of Drug Addiction in LjubljanaLjubljanaSlovenia
| | | | - Lorenzo Somaini
- Addiction Treatment Centre ‐ Ser.D ASL BI ‐ Local Health UnitBiellaItaly
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19
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Elimination of hepatitis C virus infection among people who use drugs: Ensuring equitable access to prevention, treatment, and care for all. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:1-10. [PMID: 31345644 DOI: 10.1016/j.drugpo.2019.07.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 12/12/2022]
Abstract
There have been major strides towards the World Health Organization goal to eliminate hepatitis C virus (HCV) infection as a global public health threat. The availability of simple, well-tolerated direct-acting antiviral therapies for HCV infection that can achieve a cure in >95% of people has provided an important tool to help achieve the global elimination targets. Encouragingly, therapy is highly effective among people receiving opioid agonist therapy and people who have recently injected drugs. Moving forward, major challenges include ensuring that new infections are prevented from occurring and that people who are living with HCV are tested, linked to care, treated, receive appropriate follow-up, and have equitable access to care. This editorial highlights key themes and articles in a special issue focusing on the elimination of HCV among people who inject drugs. An overarching consideration flowing from this work is how to ensure equitable access to HCV treatment and care for all. This special issue maps the field in relation to: HCV prevention; the cascade of HCV care; strategies to enhance testing, linkage to care, and treatment uptake; and HCV treatment and reinfection. In addition, papers draw attention to the 'risk environments' and socio-ecological determinants of HCV acquisition, barriers to HCV care, the importance of messaging around the side-effects of new direct-acting antiviral therapies, the positive transformative potential of treatment and cure, and the key role of community-based drug user organizations in the HCV response. While this special issue highlights some successful efforts towards HCV elimination among people who inject drugs, it also highlights the relative lack of attention to settings in which resources enabling elimination are scarce, and where elimination hopes and potentials are less clear, such as in many low and middle income countries. Strengthening capacity in areas of the world where resources are more limited will be a critical step towards ensuring equity for all so that global HCV elimination among PWID can be achieved.
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Harrison GI, Murray K, Gore R, Lee P, Sreedharan A, Richardson P, Hughes AJ, Wiselka M, Gelson W, Unitt E, Ratcliff K, Orton A, Trinder K, Simpson C, Ryder SD, Oelbaum S, Foster GR, Christian A, Smith S, Thomson BJ, Reynolds R, Harris M, Hickman M, Irving WL. The Hepatitis C Awareness Through to Treatment (HepCATT) study: improving the cascade of care for hepatitis C virus-infected people who inject drugs in England. Addiction 2019; 114:1113-1122. [PMID: 30694582 DOI: 10.1111/add.14569] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/17/2018] [Accepted: 01/24/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Previous studies have shown low rates of diagnosis and treatment of hepatitis C virus (HCV) infection in people who inject drugs (PWID). Our aims were to test the effect of a complex intervention [Hepatitis C Awareness Through to Treatment (HepCATT)] in drug and alcohol clinics-primarily, on engagement of HCV-positive PWID with therapy and, secondarily, on testing for HCV, referral to hepatology services and start of HCV treatment. DESIGN AND SETTING A non-randomized pilot study in three specialist addiction clinics in England comparing an intervention year (starting between September 2015 and February 2016) with a baseline year (2014), together with three control clinics. PARTICIPANTS Analysis included all attendees at the intervention and control specialist addiction clinics identified as PWID. INTERVENTION The intervention comprised the placement of a half-time facilitator in each clinic for 12 months with the brief to increase diagnosis of HCV infection within clients at those services and the engagement of diagnosed individuals with an appropriate care pathway. The facilitator undertook various activities, which could include training of key workers, direct interaction with clients, streamlining and support for hepatology appointments and introduction of dried blood-spot testing. MEASUREMENTS For each clinic and period, we obtained the total number of clients and, as relevant, their status as PWID, tested for HCV, known HCV-positive, engaged with HCV therapy or treated. FINDINGS Compared with baseline, there was strong evidence that engagement with HCV therapy in the intervention year increased (P < 0.001) more in the HepCATT centres than controls, up + 31 percentage points [95% confidence interval (CI) = 19-43] versus -12 (CI = -31 to + 6) and odds ratio (OR) = 9.99 (CI = 4.42-22.6) versus 0.35 (CI = 0.08-1.56). HepCATT centres also had greater increases in HCV testing (OR = 3.06 versus 0.78, P < 0.001), referral to hepatology (OR = 9.60 versus 0.56, P < 0.001) and treatment initiation (OR = 9.5 versus 0.74, P < 0.001). CONCLUSIONS Introducing a half-time facilitator into drug and alcohol clinics in England increased engagement of HCV-positive people who inject drugs with hepatitis C virus care pathways, with increased uptake also of testing, referral to hepatology and initiation of treatment.
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Affiliation(s)
- Graham I Harrison
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Karen Murray
- United Lincolnshire Hospitals Lincoln County Hospital, Lincoln, UK
| | - Roxanne Gore
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | | | - Paul Richardson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | | | - Martin Wiselka
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Will Gelson
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Esther Unitt
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | | | | | | | | | | | | | | | - Rosy Reynolds
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Magdalena Harris
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - William L Irving
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
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