Carla Treloar

Knowledge and Attitudes about Treatment for Hepatitis C Virus Infection and Barriers to Treatment among Current Injection Drug Users in Australia

Despite recent improvements in outcomes of treatment for infection with hepatitis C virus (HCV), very few current injection drug users (IDUs) have access to treatment programs. We examined the natural history of and treatment knowledge about HCV infection and barriers and willingness to seek treatment for HCV infection. A convenience sample of current IDUs (n=100) with self-reported HCV-positive status drawn from a primary health facility and methadone clinic in inner Sydney completed an interviewer-administered questionnaire. Participants had a reasonable knowledge of the natural history of HCV infection but poorer knowledge of treatment for HCV infection. Most believed that being a current IDU was an exclusion criterion for treatment. Despite this, 70%-80% of IDUs reported that they would consider treatment under current scenarios in Australia: requirement for liver biopsy, subcutaneous injections, common adverse effects, and 40% efficacy. Study participants at the methadone clinic had higher levels of consideration of treatment. These findings support the development of specific education programs regarding treatment for HCV infection for current IDUs.

Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study.

BACKGROUND Access to hepatitis C virus (HCV) treatment remains extremely limited among people who inject drugs (PWID). HCV assessment and treatment was evaluated through an innovative model for the provision of HCV care among PWID with chronic HCV infection. METHODS Enhancing Treatment for Hepatitis C in Opioid Substitution Settings (ETHOS) was a prospective observational cohort. Recruitment was through 5 opioid substitution treatment (OST) clinics, 2 community health centers, and 1 Aboriginal community controlled health organization in New South Wales, Australia. RESULTS Among 387 enrolled participants, mean age was 41 years, 71% were male, and 15% were of Aboriginal ethnicity. Specialist assessment was undertaken in 191 (49%) participants, and 84 (22%) commenced interferon-based treatment. In adjusted analysis, HCV specialist assessment was associated with non-Aboriginal ethnicity (adjusted odds ratio [AOR], 4.02; 95% confidence interval [CI], 2.05-7.90), no recent benzodiazepine use (AOR, 2.06; 95% CI, 1.31-3.24), and non-1 HCV genotype (AOR, 2.13; 95% CI, 1.32-3.43). In adjusted analysis, HCV treatment was associated with non-Aboriginal ethnicity (AOR, 4.59; 95% CI, 1.49-14.12), living with the support of family and/or friends (AOR, 2.15; 95% CI, 1.25-3.71), never receiving OST (AOR, 4.40; 95% CI, 2.27-8.54), no recent methamphetamine use (AOR, 2.26; 95% CI, 1.12-4.57), and non-1 HCV genotype (AOR, 3.07; 95% CI, 1.67-5.64). CONCLUSIONS HCV treatment uptake was relatively high among this highly marginalized population of PWID. Potentially modifiable factors associated with treatment include drug use and social support.

The Lived Experience of Hepatitis C and its Treatment Among Injecting Drug Users: Qualitative Synthesis

Hepatitis C virus infection is a stigmatized condition because of its close association with injecting drug use. There is a need to explore how people who inject drugs (IDUs) perceive hepatitis C, including in relation to treatment experience. We undertook a review, using a qualitative synthesis approach, of English-language qualitative research focusing on the lived experience of hepatitis C among IDUs. The review included 25 published articles representing 20 unique studies. A synthesis of this literature generated three interplaying themes: social stigma, biographical adaptation, and medical and treatment encounters. Interactions with health systems can reproduce stigma linked to drug injecting and hepatitis C, as well as trivialize the lived experience of diagnosis and illness. Hepatitis C can be biographically reinforcing of socially accommodated risk and spoiled identity, as well as disruptive to everyday life. We hypothesize hepatitis C as a liminal illness experience, oscillating between trivial and serious, normalized and stigmatized, public and personal. We conclude by emphasizing the disconnects between the lived experience of hepatitis C among IDUs and Western health care system responses.

‘Spoiled identity’ in hepatitis C infection: The binary logic of despair

Hepatitis C is a potentially debilitating disease of the liver, the impact of and prognosis for which vary significantly from person to person. Although the health consequences of contracting hepatitis C are extremely diverse, becoming infected with the disease is sometimes experienced in terms of an absolute shift from healthy to sick, clean to contaminated, good to bad. In this paper, we use interview material derived from a study on hepatitis C and blood awareness to look at one rarely discussed response to diagnosis with hepatitis C: a sense of despair and absolute contamination, leading to a belief that contraction of other blood-borne viruses is of no consequence. By considering the effects of hepatitis C diagnosis in light of Goffmans theory of stigma, and by linking stigmatization to the binary logic common to thinking about infection, health and identity, we offer a starting point for designing health-promotion materials that minimize despairing responses to infection.

The gendered context of initiation to injecting drug use: evidence for women as active initiates

This paper explores differences between womens and mens first experience of injecting in relation to socio-demographic context, drug use, and the role of others. We collected cross-sectional retrospective data from 334 recently initiated (<or=5 years) injecting drug users in New South Wales and Queensland, Australia using a structured questionnaire in face-to-face interviews. Logistic regression was used to estimate crude and adjusted odds ratios (OR). Findings from the adjusted analysis show that women had a shorter duration of illicit drug use prior to initiation (adjusted OR 0.84, 95%CI: 0.74 - 0.94), and were more likely to have their romantic-sexual partner facilitate the initiation by paying for the drugs (adjusted OR 4.64, 95%CI: 1.21 - 17.73). Women also reported a greater likelihood of being initiated in groups of other women (adjusted OR 2.87, 95%CI: 1.24 - 6.67), suggesting that some women play an active role in their initiation experience rather than relying on, or being lead by, a romantic-sexual partner. These findings demonstrate the crucial role that romantic-sexual partners play in womens initiation experience, but also provide evidence for the way that women can be active participants in their own initiation and in initiating other women.

Factors associated with specialist assessment and treatment for hepatitis C virus infection in New South Wales, Australia

Summary.  Assessment and treatment for hepatitis C virus (HCV) in the community remains low. We evaluated factors associated with HCV specialist assessment and treatment in a cross‐sectional study to evaluate treatment considerations in a sample of 634 participants with self‐reported HCV infection in New South Wales, Australia. Participants having received HCV specialist assessment (n = 294, 46%) were more likely to be have been older (vs <35 years; 35–44 OR 1.64, P = 0.117; 45–54 OR 2.00, P = 0.024; ≥55 OR 5.43, P = 0.002), have greater social support (vs low; medium OR 3.07, P = 0.004; high OR 4.31, P < 0.001), HCV‐related/attributed symptoms (vs none; 1–10 OR 3.89, P = 0.032; 10–21 OR 5.01, P = 0.010), a diagnosis of cirrhosis (OR 2.40, P = 0.030), have asked for treatment information (OR 1.91, P = 0.020), have greater HCV knowledge (OR 2.49, P = 0.001), have been told by a doctor to go onto treatment (OR 3.00, P < 0.001), and less likely to be receiving opiate substitution therapy (OR 0.10, P < 0.001) and never to have seen a general practitioner (OR 0.24, P < 0.001). Participants having received HCV treatment (n = 154, 24%) were more likely to have greater fibrosis (vs no biopsy; none/minimal OR 3.45, P = 0.001; moderate OR 11.47, P < 0.001; severe, OR 19.51, P < 0.001), greater HCV knowledge (OR 2.57; P = 0.004), know someone who has died from HCV (OR 2.57, P = 0.004), been told by a doctor to go onto treatment (OR 3.49, P < 0.001), were less likely to have been female (OR 0.39, P = 0.002), have recently injected (OR 0.42, P = 0.002) and be receiving opiate substitution therapy (OR 0.22, P < 0.001). These data identify modifiable patient‐, provider‐ and systems‐level barriers associated with HCV assessment and treatment in the community that could be addressed by targeted interventions.

Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs

INTRODUCTION AND AIMS Uptake of treatment for hepatitis C virus (HCV) infection among people who inject drugs is low. Further understanding is required of the relationship between HCV knowledge and treatment willingness, assessment and treatment in this population. DESIGN AND METHODS A cross-sectional self-administered survey was conducted with clients of four opioid substitution therapy (OST) clinics and the Medically Supervised Injecting Centre in Sydney, Australia. RESULTS Of 132 participants, 85 (64%) self-reported having HCV infection. HCV knowledge was mixed (mean 6.5, range 0-12) and was relatively lower on items measuring knowledge of factors impacting HCV-related disease progression. The likelihood of being in a higher knowledge category was associated with being female [adjusted odds ratio (AOR) = 3.78, 95% confidence interval (CI) (1.79, 7.98)], higher formal education [AOR = 3.28, 95% CI (1.57, 6.88)], being on a current OST program [AOR = 2.61, 95% CI (1.10, 6.19)] and being older [AOR = 1.04, 95% CI (1.01, 1.09)]. Participants receiving OST were more likely to report higher willingness to have HCV treatment [OR = 4.45, 95% CI (2.23, 8.17)]. Having been assessed for HCV treatment was associated with younger age [AOR = 0.93; CI 95% (0.88, 1.00)] and higher formal education [AOR = 7.81; 95% CI (1.62, 37.71)]. DISCUSSION AND CONCLUSIONS Overall, knowledge scores were mid-range. Knowledge of modifiable factors influencing HCV-related liver disease progression was particularly low indicating the need for ongoing education. Education should also be targeted at older people and those not on OST, and be inclusive of those with lower literacy levels.

Deficit models and divergent philosophies: Service providers’ perspectives on barriers and incentives to drug treatment

Aims: To ascertain service providers’ views on barriers and incentives to illicit drug users accessing or remaining in treatment. Methods: Interviews with service providers in Australia were conducted. Results: Two main themes were explored. Service providers suggested that the perception of a person seeking treatment was strongly associated with the image of that person as deficient, defective or lacking, and that this could impede treatment. Service providers also suggested that differing treatment philosophies and their related treatment goals were at the core of many barriers to treatment. We argue that it is important to find a balance between a model of treatment which works and is responsive to clients’ needs while also avoiding the potential for feeding stigma of those who seek treatment for drug dependence. Conclusion: Our results suggest that knowledge and understanding of treatment philosophies are important for people seeking treatment so that clients can find services that match their needs and treatment goals.

Hepatitis C and injecting-related discrimination in New South Wales, Australia

Hepatitis C-related discrimination is reportedly common, however few studies have investigated this phenomenon. This paper presents findings from a cross-sectional study of people with self-reported hepatitis C virus (HCV) infection (N = 504) conducted in New South Wales (NSW), Australia throughout 2001 and 2002. Participants completed a self-administered questionnaire enquiring into their experience of living with HCV. Over a half of the participants (57.5%, n = 290) reported that they had acquired their infection from injecting drug use. Discrimination was reported by 64.7% (n = 326) of participants and healthcare was the most commonly reported site where discrimination occurred. A logistic regression identified the predictors of any discrimination as: knowing many other people with HCV infection; feeling tired due to HCV symptoms; and being younger (<51 years). Predictors of higher levels of discrimination were: knowing many other people with HCV infection; being limited in the time spent with family, friends, neighbours and groups due to HCV; and feeling pessimistic about HCV treatment and the future because of HCV-related ill health. Although discrimination occurred in a range of social domains, effort is needed to improve healthcare workers’ service delivery to people with HCV. Continued discrimination may inhibit people from seeking a range of health services and impede efforts to contain the epidemic.

Ethical challenges and responses in harm reduction research: promoting applied communitarian ethics

Harm reduction is often defined as value-neutral with regard to drug use and drug users. In this paper Fry, Treloar & Maher argue that to its detriment, harm reduction research (and practice), in its focus on technical skills, evidence and innovation, has failed to articulate an agreed moral framework. Using case examples from a recent forum on the topic, they make a case for a more ethically engaged harm reduction. Recent debate about ethical issues within harm reduction occurs against similar discussion in public health. The authors explain that crucial issues emerge at intersections between human rights, consumer engagement and applied communitarian ethics.Simon Lenton Editor, Harm Reduction Digest