Gaps in HCV Knowledge and Risk Behaviors among Young Suburban People Who Inject Drugs. Int J Environ Res Public Health. 2019;16:1958. [PMID: 31159479 PMCID: PMC6604001 DOI: 10.3390/ijerph16111958]

Network ethnic homophily and injection equipment sharing among Latinx and White non-Latinx people who inject drugs

Latinx people who inject drugs (PWID) are less likely to engage in injection equipment sharing, but are more vulnerable to injection drug use (IDU)-related morbidity and mortality than Whites. Identifying subgroups of Latinx PWID who do engage in equipment sharing and likely bear the brunt of this health burden is a priority. Ethnic disparities may reflect contextual drivers, including injection networks. Latinx PWID with low ethnic homophily (the proportion of individuals with the same ethnic background) may be more likely to share equipment due to forced distancing from health-protective ethnocultural resources and power imbalances within injection networks. The current study offers a framework and examines how associations between network ethnic homophily and injection equipment sharing differ among 74 Latinx and 170 non-Latinx White PWID in the Chicagoland area (N = 244). Latinx had less homophilous than non-Latinx Whites (p <.001). Ethnic homophily was protective for equipment sharing among Latinx (OR = 0.17, 95%CI [0.77, 0.04], p = .02), but not non-Latinx Whites (OR = 1.66, 95%CI [0.40, 6.93], p = .49). Our findings implicate the need for targeted cultured interventions that focus on Latinx PWID who are more vulnerable to morbidity and mortality, potentially due to less access to ethnic peers.

Characterizing Persons With HIV/HCV Coinfection Who Remain Untreated for Hepatitis C at Four HIV Clinics in Connecticut (CT): Role of Multiple Overlapping Barriers at the Individual and Clinic System Levels

Introduction. Direct-acting antiviral medications have made hepatitis C virus (HCV) cure possible for >95% of persons with chronic HCV infection, including those coinfected with HIV. Achieving strategic HCV elimination targets requires an understanding of system, provider, and patient-level barriers to treatment. We explored such barriers among persons with HIV/HCV coinfection who remained untreated for HCV. Methods. Among four primary care HIV clinics in CT with high rates of HCV cure, 25 patients with HIV/HCV coinfection were eligible (no HCV treatment as of March 31, 2021). We conducted retrospective chart reviews of demographics, clinical practice patterns, patient-specific issues such as housing, transportation, food security, and presence of mental health and substance use problems. Results. Among untreated patients, 13 (51%) were female; 17 (68%) were Black; median age was 62 years old. The majority (84%) had injecting drug use (IDU) as HIV transmission risk factor; 14 (56%) were prescribed medication-assisted treatment. Median time since HIV and HCV diagnosis was 25 and 19 years, respectively. Clinic-level barriers were noted in 19 (76%) and included lack of evaluation, treatment not recommended or implemented. Concomitant structural barriers included unstable housing for 11 (44%) and lack of transportation for eight (32%). Most patients had history of illicit substance use (84%) and mental health issues (68%). Many (76%) had multiple potential barriers. Conclusions. Multiple overlapping barriers spanning clinic and patient level domains including social determinants of health were the norm in persons with long-standing HIV/HCV coinfection who have not received HCV treatment. Interventions will require innovative, multi-disciplinary and personalized approaches.

Factors associated with sharing equipment among people who inject drugs: The role of community attachment in harm reduction and health promotion

INTRODUCTION

Sharing injecting equipment is a major route of transmission for blood borne viruses such as hepatitis C and HIV. Although needle and syringe programs are widely available throughout metropolitan Australia, rates of sharing equipment have not significantly changed in recent years. This study aimed to identify factors associated with recent equipment sharing among people who inject drugs in Australia.

METHODS

A paper-based survey was distributed via peer-based organisations between June and November 2018 and was completed by 603 participants. Survey questions addressed recent injecting experiences, equipment sharing, community attachment, stigma and wellbeing. Participants who had recently shared injecting equipment were compared with those who had not shared any equipment using multivariable logistic regression.

RESULTS

Recent equipment sharing was associated with recent heroin use, experiencing any past-year stigma related to injecting drug use, and higher levels of attachment to a community of people who inject drugs. An interaction effect showed increased community attachment was associated with increased odds of sharing equipment among young participants, but with decreased odds of sharing equipment among older participants.

DISCUSSION AND CONCLUSIONS

Community networks of people who inject drugs can play important roles in harm reduction initiatives. While being connected with a community of people who inject drugs increased the odds of sharing injecting equipment, this community connection also increases opportunities for social support, sharing information and mitigating the negative effects of stigma. Collaboratively and meaningfully engaging with communities of people who inject drugs has the potential to increase the reach and effectiveness of health promotion services.

Hepatitis C antibody prevalence and behavioral correlates in people who inject drugs attending harm reduction services in Lisbon, Portugal

The hepatitis C virus (HCV) infection is an important public health problem, affecting millions of people worldwide. People who inject drugs (PWID) are at increased risk of HCV infection due to, among other factors, widespread unsafe injecting practices, such as sharing of infected equipment or unprotected sexual practices. In Portugal, there is a lack of data regarding the proportion of infected persons through injecting drug use. This study aimed to evaluate the anti-HCV prevalence and behavioral correlates of infection in PWID attending harm reduction services in the Metropolitan Area of Lisbon, Portugal. A cross-sectional study with a purposive sample of PWID was undertaken between March 2018 and March 2020. Participants were recruited through the harm-reduction services of a nongovernmental organization. A rapid diagnostic test for anti-HCV screening was performed. Data on drug consumption history and current practices, past HCV testing, care and treatment history, and knowledge regarding hepatitis C were also collected through a questionnaire applied by trained inquirers. A total of 176 PWID participated in this study. An overall prevalence of 70.5% of anti-HCV positive in this population was found. Those with an anti-HCV positive testing result tended to start consuming at a younger age and have a higher consumption of benzodiazepines in the last 30 days. Sharing needles and other injecting material is a frequent risk behavior among this group. Also, they are more likely to have attended an opioid agonist treatment and to have undertaken previous hepatitis C and HIV tests in the past. This study represents an important effort to better understand the HCV prevalence and behavioral correlates of infection among PWID in Portugal, as well as to better estimate those in need of HCV treatment.

Conceptualizing the Socio-Built Environment: An Expanded Theoretical Framework to Promote a Better Understanding of Risk for Nonmedical Opioid Overdose Outcomes in Urban and Non-Urban Settings

Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.

Hepatitis C antibody prevalence, correlates and barriers to care among people who inject drugs in Central California

Hepatitis C (HCV) infection among people who inject drugs (PWID) is a major public health concern. We examined correlates of HCV antibody (anti-HCV) seropositivity and characteristics of prior HCV testing and treatment among PWID in Fresno, California, which has among the highest prevalence of injection drug use (IDU) in the United States. We surveyed 494 peer-recruited PWID (≥18 years of age) in 2016 about their experiences with HCV testing and treatment, and conducted HCV and HIV antibody testing for all participants. Bivariate analyses and multivariable logistic regressions were used to identify correlates of anti-HCV seropositivity. A majority (65%) tested positive for anti-HCV, with 32% of those being unaware of their HCV status. Anti-HCV seroprevalence was independently and positively associated with older age (AOR = 1.11 per year, 95% CI = 1.06, 1.17), years injecting (AOR = 1.08 per year, 95% CI = 1.03, 1.13), distributive syringe sharing (AOR = 2.76, 95% CI = 1.29, 5.94), having syringes confiscated by police (AOR = 2.65, 95% CI = 1.22, 5.74), ever trading sex (AOR = 3.51, 95% CI = 1.40, 8.81) and negatively associated with being Black/African American (non-Hispanic) (AOR = 0.06, 95% CI = 0.01, 0.47). Prior HCV testing was associated with older age, ever getting syringes from a syringe services program, and having interactions with police. For those aware of their anti-HCV seropositivity, only 11% had initiated treatment; reasons for not seeing a physician regarding diagnosis included not feeling sick (23%), currently using drugs/alcohol (19%) and not knowing where to go for HCV medical care (19%). Our findings highlight the importance of expanding community-based access to sterile syringes alongside HCV testing and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking testing and treatment.

"If I Get Cured, My Whole Quality of Life Will Change": Patients' Anticipated and Actualized Benefits Following Cure from Chronic Hepatitis C

BACKGROUND

Patients' motivations for undergoing direct-acting antiviral (DAA) therapy for chronic hepatitis C may include anticipation of treatment benefits not well described in the literature.

AIMS

Evaluate patients' anticipated and actualized improvements in several domains of functioning before and after viral cure.

METHODS

Pre-post-study utilizing in-depth interviews with 28 patients prior to, and several months after, DAA therapy. Interviews were audio-recorded, transcribed, coded, and analyzed by two qualitative experts.

RESULTS

Patients had a median age of 54 years, 43% were male, 57% white, 25% had cirrhosis, and 71% were treated with sofosbuvir/ledipasvir. Pre-treatment, patients hoped for improvements in several domains including psychological, emotional, physical, social, and occupational functioning. After viral cure, increased energy and less fear of transmission were pathways to better quality of life. Psychological and emotional improvements positively affected physical, social, and occupational functioning. Social improvements were due to better mood and motivation, fewer symptoms, and reduced fear of stigma and transmission. Occupational benefits were linked to increased stamina, self-confidence, and less pain, anxiety, and stigma. Reduced fear of stigma had a pervasive impact on all life improvements after cure. Patient characteristics such as the presence of cirrhosis or psychiatric issues influence treatment motivations. Qualitative data correspond with change in pre-post-survey scores.

CONCLUSIONS

Tremendous hope is placed on the ability of DAA therapy to bring about substantial improvements in life functioning after viral cure. Highly interconnected effects on quality of life worked synergistically through improved physical and psychological well-being. Stakeholders should appreciate the multi-dimensional benefits that viral eradication bestows upon individuals and society.

Acceptability of an mHealth App That Provides Harm Reduction Services Among People Who Inject Drugs: Survey Study

Background

Harm reduction services reduce the negative consequences of drug injection and are often embedded within syringe service programs (SSPs). However, people who inject drugs (PWID) suboptimally engage with such services because of stigma, fear, transportation restrictions, and limited hours of operation. Mobile health (mHealth) apps may provide an opportunity to overcome these barriers and extend the reach of SSPs beyond that of the traditional brick-and-mortar models.

Objective

This study aims to assess the prevalence of smartphone ownership, the level of comfort in providing the personal information required to use mHealth apps, and interest in using an mHealth app to access harm reduction services among PWID to guide the development of an app.

Methods

We administered a survey to 115 PWID who were enrolled via respondent-driven sampling from July 2018 to July 2019. We examined the extent to which PWID had access to smartphones; were comfortable in providing personal information such as name, email, and address; and expressed interest in various app-based services. We measured participant characteristics (demographics, health status, and behaviors) and used binary logistic and Poisson regressions to identify independent correlates of mHealth-related variables. The primary regression outcomes included summary scores for access, comfort, and interest. The secondary outcomes included binary survey responses for individual comfort or interest components.

Results

Most participants were White (74/105, 70.5%), male (78/115, 67.8%), and middle-aged (mean=41.7 years), and 67.9% (74/109) owned a smartphone. Participants reported high levels of comfort in providing personal information to use an mHealth app, including name (96/109, 88.1%), phone number (92/109, 84.4%), email (85/109, 77.9%), physical address (85/109, 77.9%), and linkage to medical records (72/109, 66.1%). Participants also reported strong interest in app-based services, including medication or sterile syringe delivery (100/110, 90.9%), lab or appointment scheduling (90/110, 81.8%), medication reminders (77/110, 70%), educational material (65/110, 59.1%), and group communication forums (64/110, 58.2%). Most participants were comfortable with the idea of home delivery of syringes (93/109, 85.3%). Homeless participants had lower access to smartphones (adjusted odds ratio [AOR] 0.15, 95% CI 0.05-0.46; P=.001), but no other participant characteristics were associated with primary outcomes. Among secondary outcomes, recent SSP use was positively associated with comfort with the home delivery of syringes (AOR 3.29, 95% CI 1.04-10.3 P=.04), and being older than 50 years was associated with an increased interest in educational materials (AOR 4.64, 95% CI 1.31-16.5; P=.02) and group communication forums (AOR 3.69, 95% CI 1.10-12.4; P=.04).

Conclusions

Our findings suggest that aside from those experiencing homelessness or unstable housing, PWID broadly have access to smartphones, are comfortable with sharing personal information, and express interest in a wide array of services within an app. Given the suboptimal access to and use of SSPs among PWID, an mHealth app has a high potential to address the harm reduction needs of this vulnerable population.

Adherence to clinical follow-up recommendations for liver function tests: A cross-sectional study of patients with HCV and their associated risk behaviors

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We examined adherence and associated behavioral factors of HCV patients to testing guidelines.

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Injection drug users were less likely to adhere to physician recommendations.

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Improved testing adherence requires better patient-provider communication.

This study examined whether patients with Hepatitis C virus (HCV) infection adhered to their physicians’ recommendation and HCV clinical guidelines for obtaining a regular liver function test (LFT), and whether high-risk behaviors are associated with behavioral adherence. A cross-sectional survey was administered to 101 eligible patients with HCV who were recruited from health centers in New Jersey and Washington, DC. Adherence outcomes were defined as the patients’ self-report of two consecutive receipts of LFTs in accordance with their physicians’ recommended interval or the clinical guidelines for a LFT within 3–6 months. 67.4% of patients (66/98) reported a receipt of their physicians’ recommendation for a LFT. The rate of adherence to physician recommendation was about 70% (46/66), however over 50% (52/101) of patients with HCV did not obtain regular LFTs. 15.8% (16/101) of patients continued to use injection drugs. Patients who used injection drugs had 0.87 (adjusted odds ratio (aOR) = 0.13, 95% confidence interval 0.03–0.59) times lower odds adhering to their physician recommendation, relative to non-users. Patients with HIV co-infection had increased odds of adhering to the clinical guidelines (odds ratio 3.41, 95% confidence interval 1.34–8.70) vs. patients who did not report HIV co-infection. Additionally, patients who had received a physician’s recommendation had 7.21 times (95% confidence interval of 2.36–22.2) greater odds adhering to the clinical guidelines than those who had not. Overall, promoting HCV patient-provider communication regarding regular LFTs and reduction of risk behaviors is essential for preventing patients from HCV-related liver disease progression.

Chronic Hepatitis C Virus Infection Modulates the Transcriptional Profiles of CD4+ T Cells

Background

Chronic hepatitis C (CHC) is associated with altered cell-mediated immune response.

Objective

The aim of the study was to characterize functional alterations in CD4⁺ T cell subsets and myeloid-derived suppressor cells (MDSCs) during chronic hepatitis C virus (HCV) infection. Methodology. The expression levels of the lineage-defining transcriptional factors (TFs) T-bet, Gata3, Rorγt, and Foxp3 in circulating CD4⁺ T cells and percentages of MDSCs in peripheral blood were evaluated in 33 patients with CHC, 31 persons, who had spontaneously cleared the HCV infection, and 30 healthy subjects. Analysis. The CD4+ T cells TFs T-bet (T-box expressed in T cells), Foxp3 (Forkhead box P3 transcription factor), Gata3 (Gata-binding protein 3), and Rorγt (retinoic-acid-related orphan receptor gamma) and activation of CD8+ T cells, as well as percentages of MDSCs, were measured by multicolor flow cytometry after intracellular and surface staining of peripheral blood mononuclear cells with fluorescent monoclonal antibodies.

Result

The patients with CHC had significantly lower percentages of CD4⁺ T cells expressing Rorγt and Gata3 and higher percentages of Foxp3-expressing CD4⁺ T cells than healthy controls and persons who spontaneously cleared HCV infection. The ratios of T-bet⁺/Gata3⁺ and Foxp3⁺/Rorγt⁺ CD4⁺ T cells were the highest in the patients with CHC. In the patients with CHC, the percentages of Gata3⁺ and Rorγt⁺ CD4⁺ T cells and the percentages of T-bet⁺ CD4⁺ T cells and CD38⁺/HLA-DR⁺ CD8⁺ T cells demonstrated significant positive correlations. In addition, the percentage of CD38⁺/HLA-DR⁺ CD8⁺ T cells correlated negatively with the percentage of MDSCs.

Conclusion

Chronic HCV infection is associated with downregulation of TFs Gata3 and Rorγt polarizing CD4+ T cells into Th2 and Th17 phenotypes together with upregulation of Foxp3 responsible for induction of regulatory T cells suppressing immune response.

Will peer-based interventions improve hepatitis C virus treatment uptake among young people who inject drugs?

People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV) and have low rates of direct-acting antiviral (DAA) treatment uptake, despite universal coverage of the medication in most Canadian settings. Investigation into peer-based interventions as a means of improving treatment uptake has yielded promising results in adult PWID populations. In this commentary, we discuss the benefits and considerations of integrating peer-based interventions into HCV care for adolescent and young adult PWID living with HCV. Given that young PWID experience high transmission rates and account for most new infections, improving strategies for youth engagement with DAA treatment is critical. We describe how peer-based interventions can feature the unique importance of peer relationships in this period of life and provide a low-barrier way of delivering health promotion messages. In particular, we discuss the ability of peer-based interventions to reshape the narrative of HCV care in young PWID peer networks by empowering youth to share experiences and knowledge with others. We conclude by addressing knowledge gaps in the literature which must be filled in order to strengthen the impact of peer-based interventions on treatment uptake rates among young PWID.

Accelerating the elimination of hepatitis C in Kuwait: An expert opinion

The hepatitis C virus (HCV) is estimated to affect 71 million people worldwide. In 2016, the World Health Organization adopted the first global health sector strategy to eliminate viral hepatitis as a public health threat by 2030. In December 2018, the European Association for the Study of the Liver, International Liver Foundation convened an expert panel to address the elimination of HCV in Kuwait. Several steps have already been taken to eliminate HCV in Kuwait, including free HCV treatment for Kuwait's citizens, high blood safety standards, and the implementation of screening and awareness programs. The expert panel made several recommendations aimed at accelerating the elimination of HCV in Kuwait: The development of a national strategy and action plan to guide all HCV elimination activities; the formation of a coordination mechanism to support collaboration between hepatitis working committees; the prioritization of micro-elimination at primary, secondary or tertiary facilities, in prisons and rehabilitation centers; and ensuring the involvement of multiple stakeholders - including relevant civil society groups - in all activities. Enhanced screening and linkage to care should be prioritized in Kuwait, with the expansion of the prescriber base to primary healthcare providers and nurse practitioners to be considered. Raising awareness and educating people about HCV infection also remain essential to achieve the goal of HCV elimination. Lastly, a national HCV registry should be developed to help monitor the implementation of viral hepatitis plans and progress towards achieving national and international targets.

Increasing Viral Hepatitis Knowledge Among Urban Ethnic Minority Youth: Findings from a Community Based Prevention Intervention

Viral hepatitis (VH) knowledge among youth is understudied in the United States. There has been a rise in VH cases in the U.S. in the wake of the opioid epidemic. Innovative approaches to preventing the infection are needed especially in urban communities. This study presents preliminary findings from a community-based HIV/AIDS, substance abuse, and VH prevention education intervention for ethnic minority youth in a northeastern urban community. We aimed to evaluate VH knowledge and factors associated with knowledge. Participants in the study completed a baseline survey followed by an exit survey measuring VH knowledge after the intervention. The survey was completed by 691 individuals. Logistic regression analyses were conducted and indicated that there was a significant increase (82.3%) in VH knowledge among youth who participated in the intervention. The development and implementation of VH knowledge interventions can be crucial in alleviating the rise of VH infections in the U.S.

Using the barriers and facilitators to linkage to HIV care to inform hepatitis C virus (HCV) linkage to care strategies for people released from prison: Findings from a systematic review

Elimination of hepatitis C virus (HCV) among short-term sentenced prison populations will require improved access to HCV care and specific strategies dedicated to linkage upon release. Prison-based HCV care has lagged behind HIV care, but much can be learned from HIV studies. We performed a systematic review to identify individual-, provider- and system-level barriers and facilitators to linkage to HCV and HIV care among released inmates. We searched MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials and Embase, and performed a grey literature search for English articles published up to November 2018. Two searches were conducted, one each for HCV and HIV; 323 and 684 unique articles were identified of which two and 27 studies were included, respectively. Facilitators to linkage to HCV care included social support, having an existing primary care provider, and receipt of methadone, whereas barriers included a perceived lack of healthcare information and a lack of specialized linkage to care programs. The principal facilitators to linkage to HIV care included social support, treatment for substance use and mental illness, the provision of education, case management, discharge planning and transportation assistance. Important barriers were unstable housing, age <30 years, HIV-related stigma, poor providers' attitudes and the lack of post-release reintegration assistance. While HCV care-specific studies are needed, much can be learned from linkage to HIV care studies. Ultimately, a multi-pronged approach, addressing several individual-level social determinants of health, and key provider- and system-level barriers may be an appropriate starting point for the development of HCV linkage to care strategies.