M. Mofizul Islam

The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature

BACKGROUND Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IDU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population. METHODS Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents. RESULTS Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals. CONCLUSIONS Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented.

Multimorbidity and Comorbidity of Chronic Diseases among the Senior Australians: Prevalence and Patterns

Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or “attaching” themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.

The reliability of sensitive information provided by injecting drug users in a clinical setting: Clinician-administered versus audio computer-assisted self-interviewing (ACASI)

Abstract Research with injecting drug users (IDUs) suggests greater willingness to report sensitive and stigmatised behaviour via audio computer-assisted self-interviewing (ACASI) methods than during face-to-face interviews (FFIs); however, previous studies were limited in verifying this within the same individuals at the same time point. This study examines the relative willingness of IDUs to report sensitive information via ACASI and during a face-to-face clinical assessment administered in health services for IDUs. During recruitment for a randomised controlled trial undertaken at two IDU-targeted health services, assessments were undertaken as per clinical protocols, followed by referral of eligible clients to the trial, in which baseline self-report data were collected via ACASI. Five questions about sensitive injecting and sexual risk behaviours were administered to participants during both clinical interviews and baseline research data collection. “Percentage agreement” determined the magnitude of concordance/discordance in responses across interview methods, while tests appropriate to data format assessed the statistical significance of this variation. Results for all five variables suggest that, relative to ACASI, FFI elicited responses that may be perceived as more socially desirable. Discordance was statistically significant for four of the five variables examined. Participants who reported a history of sex work were more likely to provide discordant responses to at least one socially sensitive item. In health services for IDUs, information collection via ACASI may elicit more reliable and valid responses than FFI. Adoption of a universal precautionary approach to complement individually tailored assessment of and advice regarding health risk behaviours for IDUs may address this issue.

Twenty-year trends in benzodiazepine dispensing in the Australian population

Considerable concern has been expressed about overprescribing of benzodiazepines and related harms. Past analyses have relied on World Health Organization‐defined daily doses (DDD) which are sometimes out of keeping with clinical usage. This study examines 20‐year (1992–2011) trends of benzodiazepine dispensing in Australia using both DDD and Ashton equivalent dose.

An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions

BackgroundIn an effort to control non-medical use and/or medical abuse of prescription drugs, particularly prescription opioids, electronic prescription drug monitoring programs (PDMP) have been introduced in North-American countries, Australia and some parts of Europe. Paradoxically, there are simultaneous pressures to increase opioid prescribing for the benefit of individual patients and to reduce it for the sake of public health, and this pressure warrants a delicate balance of appropriate therapeutic uses of these drugs with the risk of developing dependence. This article discusses pros and cons of PDMP in reducing diversion of prescription opioids, without hampering access to those medications for those with genuine needs, and highlights tensions around PDMP implementation.DiscussionPDMPs may help alleviate diversion, over-prescription and fraudulent prescribing/dispensing; prompt drug treatment referrals; avoid awkward drug urine test; and inform spatial changes in prescribing practices and help designing tailored interventions. Fear of legal retribution, privacy and data security, potential confusion about addiction and pseudo-addiction, and potential undue pressure of detecting misuse/diversion - are the major problems. There are tensions about unintended consequence of excessive regulatory enforcements, corresponding collateral damages particularly about inadequate prescribing for patients with genuine needs, and mandatory consultation requirements of PDMP.SummaryIn this era of information technology PDMP is likely to flourish and remain with us for a long time. A clear standard of practice against which physicians’ care will be judged may expedite the utilisation of PDMP. In addition, adequate training on addiction and pain management along with public awareness, point-of-supply data entry from pharmacy, point-of-care real-time access to data, increasing access to addiction treatment and appropriate regulatory enforcement preferably through healthcare administration, together, may help remove barriers to PDMP use.

HIV and sexual risk behaviors among recognized high-risk groups in Bangladesh : need for a comprehensive prevention program

OBJECTIVE To examine trends in HIV and related risk behaviors among recognized high-risk groups in Bangladesh, the types and extent of prevention initiatives that have been undertaken, and highlight the immediate needs. METHODS Journal publications and conference abstracts and proceedings were reviewed. Experts involved in the development and evaluation of current programs or policy were contacted for official reports and policy documents. The trends in sexual risk behaviors over five rounds of national surveillance were tabulated. Gaps in the ongoing prevention interventions have been assessed in the light of the Anderson-May equation. RESULTS Periodic surveillance on recognized high-risk groups shows that HIV prevalence has been increasing steadily. In the capital city, HIV prevalence in one subset of a high-risk group is close to the level of a concentrated epidemic (4.9%). The high prevalence of sexual risk behaviors among drug users and sex workers and their clients is alarming. Although a small increase in condom use and a reduction of syphilis have been noted among subsets of high-risk groups in recent years, this is clearly not enough to curb the threat of a possible HIV epidemic. CONCLUSION There is an urgent need for a comprehensive prevention program that should include more efforts on education and condom promotion, effective management of all sexually transmitted infections, a screening program for migrant workers, the continuation of both behavioral and serological components of HIV surveillance, and the expansion of surveillance to cover the remaining high-risk groups, with due consideration to the consistency of surveillance indicators.

Assessing the role of syringe dispensing machines and mobile van outlets in reaching hard-to-reach and high-risk groups of injecting drug users (IDUs): a review

Reaching hard-to-reach and high-risk injecting drug users (IDUs) is one of the most important challenges for contemporary needle syringe programs (NSPs). The aim of this review is to examine, based upon the available international experience, the effectiveness of syringe vending machines and mobile van/bus based NSPs in making services more accessible to these hard-to-reach and high-risk groups of IDUs. A literature search revealed 40 papers/reports, of which 18 were on dispensing machines (including vending and exchange machines) and 22 on mobile vans. The findings demonstrate that syringe dispensing machines and mobile vans are promising modalities of NSPs, which can make services more accessible to the target group and in particular to the harder-to-reach and higher-risk groups of IDUs. Their anonymous and confidential approaches make services attractive, accessible and acceptable to these groups. These two outlets were found to be complementary to each other and to other modes of NSPs. Services through dispensing machines and mobile vans in strategically important sites are crucial elements in continuing efforts in reducing the spread of HIV and other blood borne viruses among IDUs.

Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients. This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic. Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Healthcare utilisation and disclosure of injecting drug use among clients of Australia's needle and syringe programs

Background : People who inject drugs (PWID) report limited access to healthcare, and may avoid disclosing drug use. Health service utilisation was examined among participants in the Australian Needle and Syringe Program Survey (ANSPS), an annual cross‐sectional sero‐survey of needle syringe program (NSP) attendees.

Harm reduction healthcare: From an alternative to the mainstream platform?

Despite a plethora of health-related problems, access to primary healthcare is often limited for drug users (DUs). Many seek care at emergency departments and tertiary hospitals because of late presentation of illness. The costs to both DUs and the health system are such that harm reduction based healthcare centres (HRHCs) have been established in various settings and utilising a variety of models. These provide a range of medical and sometimes social services, in one, integrated, low-threshold facility, including (or closely linked with) programs such as needle syringe provision. In some countries these HRHCs are becoming an alternative healthcare system for DUs. However, the need to provide such services on a broad, public health scale, in a sustainable, cost-effective manner, raises the question as to whether such programmes should be mainstreamed. This commentary provides insights on advantages and disadvantages to mainstreaming HRHCs, and approaches and barriers to achieving this. Two approaches suggest themselves: (i) providing harm reduction services through the regular healthcare system, or (ii) more closely integrating HRHCs with mainstream services. Funding and stigma are major barriers to mainstreaming. Diverse national policies towards DUs, healthcare systems and contexts, necessitate different approaches. Because of the various barriers to mainstreaming, any steps towards mainstreaming should be taken whilst maintaining the option of continuing the current targeted harm reduction services.