"Treated like a Human Being": perspectives of people who inject drugs attending low-threshold HCV treatment at a syringe service program in New York City

BACKGROUND

Hepatitis C virus (HCV) treatment can effectively cure HCV among people who inject drugs (PWID). Perspectives of PWID treated in innovative models can reveal program features that address barriers to treatment, and guide implementation of similar models.

METHODS

We interviewed 29 participants in the intervention arm of a randomized trial. The trial enrolled PWID with HCV in New York City from 2017 to 2020 and tested the effectiveness of a low-threshold HCV treatment model at a syringe services program. Participants were purposively sampled and interviewed in English or Spanish. The interview guide focused on prior experiences with HCV testing and treatment, and experiences during the trial. Interviews were inductively coded and analyzed using thematic analysis.

RESULTS

Before enrollment, participants reported being tested for HCV in settings such as prison, drug treatment, and emergency rooms. Treatment was delayed because of not being seen as urgent by providers. Participants reported low self-efficacy, competing priorities, and systemic barriers to treatment such as insurance, waiting lists, and criminal-legal interactions. Stigma was a major factor. Treatment during the trial was facilitated through respect from staff, which overcame stigma. The flexible care model (allowing walk-ins and missed appointments) helped mitigate logistical barriers. The willingness of the staff to address social determinants of health was highly valued.

CONCLUSION

Our findings highlight the need for low-threshold programs with nonjudgmental behavior from program staff, and flexibility to adapt to participants' needs. Social determinants of health remain a significant barrier, but programs' efforts to address these factors can engender trust and facilitate treatment. Trial registration NCT03214679.

Treatment seeking for alcohol-related issues during the COVID-19 pandemic: An analysis of an addiction-specialized psychiatric treatment facility

The COVID-19 pandemic and its societal impact may cause long-term behavioral changes in alcohol use due to increased psychological distress, unemployment, and time spent home. The purpose of this study was to determine whether or not the COVID-19 pandemic had a significant impact on treatment seeking for alcohol use disorders and related problems in a Swedish psychiatric treatment facility. Using an interrupted-time-series design on data derived from an addiction-specific psychiatric treatment facility located in Malmö, Sweden, we hypothesized that treatment seeking would decrease during the pandemic based on previous research identifying limited alcohol availability and affordability, as well as accessibility to treatment centers as influential factors. In addition, we assessed the predictive power of alcohol sales and number of active cases in the region using simple linear regressions. Results indicated that the pandemic had little to no effect on the number of people needing care, however a significant step change was found in treatment seeking patterns for unique female patients during the second wave (October 2020). Regression analyses indicated that alcohol sales and the number of active cases in the region did not significantly predict treatment seeking. A causal relationship between the onset of the pandemic and variation in treatment seeking for alcohol use could not be established. More research is needed to fully understand the pandemic's impact on alcohol use behavior change.

Risk factors for non-adherence among people with HIV-associated TB in Karnataka, India: A case-control study

SETTING

Five select districts of Karnataka, India, providing anti-tubercular and antiretroviral therapy (ATT and ART) to people with Human Immunodeficiency Virus (HIV) - associated Tuberculosis (TB) through a single window care approach at the ART centres (seven ART centres and 16 link ART centres).

OBJECTIVES

To determine the factors associated with non-adherence to concurrent therapy.

DESIGN

We conducted a case-control study involving primary and secondary data collection. Starting January 2019, we consecutively enrolled people on at least three months of ATT until we enrolled 125 cases (non-adherent to concurrent therapy) and 375 controls (adherent to concurrent therapy). Adherence was defined as taking >95% ART doses and >90% ATT doses, every month over the last three months. We performed multivariable logistic regression to identify factors associated with non-adherence.

RESULTS

The mean age of the cases and control was similar: 39.8 (standard deviation: 8.8) years. The risk factors for non-adherence were status non-disclosure (aOR = 2.06), zidovudine-based ART (aOR = 4.87), >3 side effects (aOR = 6.45), not receiving counselling before ATT initiation (aOR = 5.25) and non-receipt of co-trimoxazole prophylaxis (aOR = 9.90).

CONCLUSION

Major determinants for non-adherence were clinical and treatment related factors.

Development of an intervention system for linkage-to-care and follow-up for hepatitis B and C virus carriers

Background

Poor connections in the cascade of viral hepatitis care have been discussed around the world. In 2011 in Japan, 500,000 to 1.25 million hepatitis B and C virus carriers needed to consult with hepatologists, so linkage-to-care (LTC) needs to be promoted. Therefore, in this study, to improve LTC and care-seeking behaviors, we attempted to establish a community-based intervention system and evaluate its effectiveness by analyzing behavior modifications.

Methods

In a model city, Okazaki (population: 387,887 as of 2019), LTC was encouraged among HBV and HCV carriers by annually mailed brochures, and their care-seeking behaviors were followed up through questionnaires for 8 years (2012–2019). Their behavior modifications and demographic characteristics were analyzed anonymously in cooperation with community health workers, hepatologists, and researchers.

Results

Through regional HBsAg and anti-HCV screening, 333 HBV and 208 HCV carriers were identified. Before the intervention, only 34.7% (25/72) of HBV- and 34.3% (24/70) of HCV-positive individuals had consulted with hepatologists. However, in 2019, after the intervention, these proportions increased to 79.8% (91/114) and 91.2% (52/57), respectively. Access to outpatient care and treatment uptake also continuously improved. However, individuals over 70 years of age were significantly less likely to engage in care-seeking behaviors (p < 0.05), and significantly fewer HCV-positive females received treatment (p = 0.03).

Conclusions

A paper-based reiterative intervention encouraging LTC and follow-up successfully improved the care-seeking behaviors of hepatitis virus-positive individuals and enabled their behavior modifications to be monitored. Further trials are required to advance the system by age- and gender-specific interventions.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10269-5.

Epidemiology and treatment status of hepatitis C virus infection among people who have ever injected drugs in Korea: a prospective multicenter cohort study from 2007 to 2019 in comparison with non-PWID

OBJECTIVES

Injection drug use is a major risk factor for hepatitis C virus (HCV) infection; however, limited data on this topic are available in Korea. Thus, this study aimed to investigate the epidemiological and clinical characteristics, treatment uptake, and outcomes of HCV infection among people who inject drugs (PWID).

METHODS

We used the data from the Korea HCV cohort, which prospectively enrolled patients with HCV infection between 2007 and 2019. Clinical data and results of a questionnaire survey on lifetime risk factors for HCV infection were analyzed according to a self-reported history of injection drug use (PWID vs. non-PWID group).

RESULTS

Among the 2,468 patients, 166 (6.7%) were in the PWID group, which contained younger patients (50.6±8.2 vs. 58.2±13.1 years) and a higher proportion of male (81.9 vs. 48.8%) than the non-PWID group. The distribution of PWID showed significant regional variations. Exposure to other risk factors for HCV infection was different between the groups. The proportion of patients with genotype non-2 infection was higher in the PWID group. Treatment uptake was higher in the PWID group in the interferon era; however, it was comparable between the groups in the direct-acting antiviral era. The rate of sustained virological response did not significantly differ between the groups.

CONCLUSIONS

As of 2019, PWID constituted a minority of HCV-infected people in Korea. The epidemiological characteristics, but not treatment uptake and outcomes, were different between the PWID and non-PWID groups. Therefore, active HCV screening and treatment should be offered to PWID in Korea.

SCOPE 2021: a new scorecard for osteoporosis in Europe

This scorecard summarises key indicators of the burden of osteoporosis and its management in the 27 member states of the European Union, as well as the UK and Switzerland. The resulting scorecard elements, assembled on a single sheet, provide a unique overview of osteoporosis in Europe.

INTRODUCTION

The scorecard for osteoporosis in Europe (SCOPE) is a project of the International Osteoporosis Foundation (IOF) that seeks to raise awareness of osteoporosis care in Europe. The aim of this project was to develop a scorecard and background documents to draw attention to gaps and inequalities in the provision of primary and secondary prevention of fractures due to osteoporosis.

METHODS

The SCOPE panel reviewed the information available on osteoporosis and the resulting fractures for each of the 27 countries of the European Union plus the UK and Switzerland (termed EU27+2). The information obtained covered four domains: background information (e.g. the burden of osteoporosis and fractures), policy framework, service provision and service uptake, e.g. the proportion of men and women at high risk that do not receive treatment (the treatment gap).

RESULTS

There was a marked difference in fracture risk among the EU27+2 countries. Of concern was the marked heterogeneity in the policy framework, service provision and service uptake for osteoporotic fracture that bore little relation to the fracture burden. For example, despite the wide availability of treatments to prevent fractures, in the majority of the EU27+2, only a minority of patients at high risk receive treatment even after their first fracture. The elements of each domain in each country were scored and coded using a traffic light system (red, orange, green) and used to synthesise a scorecard. The resulting scorecard elements, assembled on a single sheet, provide a unique overview of osteoporosis in Europe.

CONCLUSIONS

The scorecard enables healthcare professionals and policy makers to assess their country's general approach to the disease and provide indicators to inform the future provision of healthcare.

Uptake and predictors of direct-acting antiviral treatment for hepatitis C among people receiving opioid agonist therapy in Sweden and Norway: a drug utilization study from 2014 to 2017

Background

Treatment with direct-acting antiviral agents (DAAs) offers an opportunity to eliminate hepatitis C virus (HCV) endemic among people who inject drugs (PWID) and people enrolled in opioid agonist therapy (OAT) programs. The objective of this study was to estimate and to compare HCV treatment uptake after the introduction of DAAs among patients receiving OAT in Sweden and Norway. We also aimed to evaluate predictors of DAAs treatment among OAT patients in both countries.

Methods

This observational study was conducted with data from The Swedish Prescribed Drug Register and The Norwegian Prescription Database. We studied dispensed medications to calculate HCV treatment among OAT patients from 2014 to 2017 in Sweden and Norway. HCV prevalence was estimated from primary and secondary sources. Dispensations of medicines from different therapeutic areas, which served as proxy for co-morbidities in 2017, were conditionally adjusted for age, gender, and OAT medications. Logistic regression was used to evaluate these parameters.

Results

In total 3529 individuals were identified with dispensed OAT in the Swedish cohort and 7739 individuals in the Norwegian cohort. HCV treatment was utilized by 407 persons in Sweden and 920 in Norway during the study period. Annual HCV and DAA treatment uptake increased in both countries. The estimated cumulative HCV treatment uptake at the end of 2017 was 31% in Norway and 28% in Sweden. DAA treatment was associated with increased age (aOR 1.8; 95% CI 1.0–3.2) and the dispensation of drugs used for diabetes (aOR 3.2; 95% CI 1.8–5.7) in Sweden. In Norway, lipid modifying agents and antibacterials were associated with decreased odds (aOR 0.4; 95%CI 0.2–0.9, aOR 0.8; 95%CI 0.6–1.0).

Conclusions

An increase in DAA treatment and HCV treatment uptake was observed among Swedish and Norwegian OAT patients whilst introducing new direct-acting antiviral treatment regimens. However, more than two thirds of the OAT population in Norway and Sweden were untreated at the beginning of 2018. A further scale-up is crucial in order to control and eliminate the HCV endemic among OAT patients.

'Good health' as a barrier and facilitator to ART initiation: a qualitative study in the era of test-and-treat in Mozambique

HIV test-and-treat programmes are being implemented throughout sub-Saharan Africa, enrolling HIV-positive clients into antiretroviral treatment (ART) immediately after diagnosis, regardless of clinical stage or CD4 count. This study conducted in Mozambique examined what influenced clients who tested HIV-positive in the context of test-and-treat to make ART initiation decisions. Eighty in-depth interviews with HIV-positive clients and nine focus group discussions with health care workers were completed across 10 health facilities. 'Good health' acted simultaneously as a barrier and facilitator; clients in good health often found a positive HIV diagnosis hard to cope with since HIV was traditionally associated with ill health. Concerns about ART side effects, fear of inadvertent HIV status disclosure and discrimination, limited privacy at health facilities and long waiting times were also barriers to initiation. In contrast, being in good health also acted as a motivator to start treatment so as to remain healthy, maintain responsibilities such as work and caring for dependents and avoid unwanted disclosure. Study findings offer an in-depth understanding of the complex dynamics between individual perceptions of 'being healthy' and its influence on ART initiation within the context of test-and-treat programme implementation.

Variation in hepatitis C virus treatment uptake between Canadian centres in the era of direct-acting antivirals

BACKGROUND

Patients co-infected with HIV and hepatitis C virus (HCV) are a priority target for HCV treatment. The simplicity and efficacy of direct-acting antivirals (DAA) should help overcome patient, provider, and structural barriers to scaling up treatment.

METHODS

We estimated between-centre variation in DAA treatment uptake among 1734 patients enrolled at the 18 centres of the Canadian Co-Infection Cohort-a prospective cohort of adults co-infected with HIV and HCV. We then compared this variation to that observed during the interferon era. Time to treatment uptake was modeled using a Weibull time-to-event model adjusting for centre and patient characteristics thought to have an impact on treatment initiation in the DAA era.

RESULTS

At the time of administrative censoring (December 31, 2016), 981 cohort participants were eligible for second-generation DAA therapy (HCV RNA positive after November 21, 2013) of whom 278 initiated DAAs (16 patients per 100 person-years). Patients with low monthly income, Indigenous ethnicity, recent injection drug use, HCV genotype 3, or unknown HCV genotype were less likely to start treatment. After adjusting for patient characteristics, the estimated between-centre variance (σ²) was 0.29 (95% credible interval [CrI]: 0.09-0.89), considerably lower than during the interferon era (σ² = 0.87, 95% CrI: 0.49-1.5). This between-centre variance was further reduced by the addition of centre-level effects for jurisdiction (σ² = 0.15, 95% CrI: 0.02-0.60).

CONCLUSION

Much of the variation in treatment uptake between centres can now be attributed to regional differences. This suggests that after the introduction of DAAs, treatment barriers have shifted towards prescribing and reimbursement restrictions based on liver fibrosis, which vary by jurisdiction. The removal of these restrictions, however, will need to be paired with strategies to overcome patient-level barriers, which continue to prevent marginalized people and active substance users from accessing treatment.

Knowledge and attitude for overactive bladder care among women: development and measurement

BACKGROUND

Overactive bladder (OAB) affects millions of women. It is important to assess knowledge and attitude in affected patients. The study objective was to develop surveys to assess OAB knowledge and OAB related attitude, and its association with OAB treatment status.

METHODS

Systematic literature review and qualitative analysis of patient and provider focus groups helped identify OAB knowledge and attitude survey items. We determined psychometric properties of the two surveys in a cross-sectional sample of 104 women, 27% of whom had received OAB treatment.

RESULTS

The OAB-knowledge survey consisted of 16 items and 3 condition-related concepts: perception of OAB; cause and information; and signs of OAB. The OAB-attitude survey consisted of 16 items and its concepts were treatment seeking; decision-making and effects. Both surveys demonstrated good construct validity and test-retest reliability ((≥ 0.60). In the cross-sectional validation sample, OAB-knowledge and attitude discriminated between those with different levels of ICIQ-UI scores. We observed some difference in the OAB knowledge, OAB attitude, and severity of symptoms between those treated for OAB vs. treatment naive.

CONCLUSIONS

OAB knowledge and attitude surveys provide a novel tool to assess OAB domains in women. Though we did not find statistical significance in OAB knowledge and attitude scores across treatment status, they may be potentially modifiable factors that affect OAB treatment uptake and treatment compliance. Refinement of these surveys in diverse sub-populations is necessary. Our study provides effect sizes for OAB knowledge and attitude. These effect sizes can help development of fully powered trials to study the association between OAB knowledge and attitude, type and length of treatment, treatment compliance, and quality of life, leading to interventions for enhancing OAB care.

Modeling HIV-HCV coinfection epidemiology in the direct-acting antiviral era: the road to elimination

BACKGROUND

HCV treatment uptake has drastically increased in HIV-HCV coinfected patients in France since direct-acting antiviral (DAA) treatment approval, resulting in HCV cure in 63% of all HIV-HCV patients by the end of 2015. We investigated the impact of scaling-up DAA on HCV prevalence in the whole HIV population and in various risk groups over the next 10 years in France using a transmission dynamic compartmental model.

METHODS

The model was based on epidemiological data from the French Dat'AIDS cohort. Eight risk groups were considered, including high-risk (HR) and low-risk (LR) men who have sex with men (MSM) and male/female heterosexuals, intra-venous drug users, or patients from other risk groups. The model was calibrated on prevalence and incidence data observed in the cohort between 2012 and 2015.

RESULTS

On January 1, 2016, 156,811 patients were registered as infected with HIV in France (24,900 undiagnosed patients) of whom 7938 (5.1%) had detectable HCV-RNA (722 undiagnosed patients). Assuming a treatment coverage (TC) rate of 30%/year (i.e., the observed rate in 2015), model projections showed that HCV prevalence among HIV patients is expected to drop to 0.81% in 2026. Sub-analyses showed a similar decrease of HIV-HCV prevalence in most risk groups, including LR MSM. Due to higher infection and reinfection rates, predicted prevalence in HR MSM remained stable from 6.96% in 2016 to 6.34% in 2026. Increasing annual TC rate in HR MSM to 50/70% would decrease HCV prevalence in this group to 2.35/1.25% in 2026. With a 30% TC rate, undiagnosed patients would account for 34% of HCV infections in 2026.

CONCLUSIONS

Our model suggests that DAA could nearly eliminate coinfection in France within 10 years for most risk groups, including LR MSM. Elimination in HR MSM will require increased TC.

Belgian experience with direct acting antivirals in people who inject drugs

BACKGROUND AND AIM

Hepatitis C viral infection (HCV) has become a curable disease due to the development of direct acting antivirals (DAA). The WHO has set a target to eliminate HCV completely. Therefore, people who inject drugs (PWID) also need to be treated. In this study, we compared the real-life uptake and outcome of DAA treatment for HCV in PWID and non-PWID.

METHODS

We performed a nation-wide, retrospective cohort study in 15 hospitals. All patients who were treated with simeprevir-sofosbuvir, daclatasvir-sofosbuvir, or ombitasvir/paritaprevir ritonavir-dasabuvir between December 2013 and November 2015 were included.

RESULTS

The study population consisted of 579 patients: 115 PWID (19.9%) and 464 non-PWID (80.1%). Of the PWID 18 were active PWID (15.6%), 35 still received opiate substitution therapy (OST) (30.4%) and 62 were former PWID without OST (53.9%). PWID were more infected with genotype 1a and 3 (p=0.001). There were equal rates of side-effects (44.7% vs. 46.6%; p=0.847), similar rates of treatment completion (95.7% vs 98.1%; p=0.244) and SVR (93.0% vs 94.8%; p=0.430) between PWID and non-PWID, respectively.

CONCLUSION

PWID, especially active users, are underserved for DAA treatment in real life in Belgium. Reimbursement criteria based on fibrosis stage make it difficult to treat PWID. Treatment adherence is similar in PWID and the general population, even in patients with active abuse. DAA were safe and effective in PWID despite the higher prevalence of difficult-to-treat genotypes. Based on these data more efforts to treat PWID are needed and policy changes are necessary to reach the WHO targets.

Direct-acting antiviral treatment against hepatitis C virus infection in HIV-Infected patients - "En route for eradication"?

OBJECTIVES

Direct-Acting Antivirals (DAAs) opened a new era in HCV treatment. We report the impact of HCV treatment in French HIV-HCV coinfected patients.

METHODS

All HIV-HCV patients from the Dat'AIDS cohort followed between 2012 and 2015 were included. HCV status was defined yearly as naive, spontaneous cure, sustained virological response (SVR12), failure or reinfection.

RESULTS

Among 32,945 HIV-infected patients, 15.2% were positive for anti-HCV antibodies. From 2012 to 2015, HCV incidence rate increased from 0.35%PY to 0.69%PY in MSM, while median incidence was 0.08%PY in other patients. Median reinfection rate was 2.56%PY in MSM and 0.22%PY in other patients. HCV treatment initiation rate rose from 8.2% in 2012 to 29.6% (48.0% in pre-treated patients vs 22.6% in naïve patients). SVR12 rate increased from 68.7% to 95.2%. By the end of 2015, 62.7% of the patients were cured either spontaneously or following SVR.

CONCLUSIONS

HCV treatment dramatically increased in HIV-HCV patients in France from 2012 to 2015 resulting in HCV cure in nearly two-thirds of the patients in this cohort. Combined with a declining HCV prevalence, the prevalence of active HCV infection among HIV patients will drastically decrease in the forthcoming years.