Barriers and facilitators for assessment and treatment of hepatitis C virus infection in the opioid substitution treatment setting: Insights from the ETHOS study

National Centre in HIV Social Research, The University of New South Wales, Sydney, NSW, Australia.
Journal of Viral Hepatitis (Impact Factor: 3.91). 12/2013; 21(8). DOI: 10.1111/jvh.12183
Source: PubMed


Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences.

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    • "Among street-based PWID in France, TE (FibroScan 1 ) had complete acceptance (100%) and led to treatment uptake for 10% of HCV-positive participants who were previously undiagnosed (Foucher et al., 2009). Hence, TE assessment may facilitate entry into care, particularly among PWID with HCV who state a lack of HCV-related symptoms as a reason to not seek assessment (Treloar et al., 2014). The LiveRLife study is a liver health promotion campaign designed to enhance liver disease assessments using TE assessment in the drug and alcohol setting among persons with a history of injection drug use. "
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    ABSTRACT: The aim of this study was to assess factors associated with baseline knowledge of HCV and liver disease, acceptability of transient elastography (TE) assessment (FibroScan(®)), and willingness and intent to receive HCV treatment among persons with a history of injection drug use participating in a liver health promotion campaign. The LiveRLife campaign involved three phases: (1) campaign resource development; (2) campaign resource testing; and (3) campaign implementation. Participants were enrolled in an observational cohort study with recruitment at four clinics - one primary health care facility, two OST clinics, and one medically supervised injecting centre - in Australia between May and October 2014. Participants received educational material, nurse clinical assessment, TE assessment, dried blood spot testing, and completed a knowledge survey. Of 253 participants (mean age 43 years), 68% were male, 71% had injected in the past month, and 75% self-reported as HCV positive. Median knowledge score was 16/23. In adjusted analysis, less than daily injection (AOR 5.01; 95% CI, 2.64-9.51) and no daily injection in the past month (AOR 3.54; 95% CI, 1.80-6.94) were associated with high knowledge (≥16). TE was the most preferred method both pre- (66%) and post-TE (89%) compared to liver biopsy and blood sample. Eighty-eight percent were 'definitely willing' or 'somewhat willing' to receive HCV treatment, and 56% intended to start treatment in the next 12 months. Approximately 68% had no/mild fibrosis (F0/F1, ≥2.5 to ≤7.4kPa), 13% moderate fibrosis (F2, ≥7.5 to ≤9.4kPa), 10% severe fibrosis (F3, ≥9.5 to ≤12.4kPa), and 9% had cirrhosis (F4, ≥12.5kPa). Liver disease and HCV knowledge was moderate. High acceptability of TE by PWID provides strong evidence for the inclusion of TE in HCV-related care, and could help to prioritise HCV treatment for those at greatest risk of liver disease progression. Copyright © 2015 Elsevier B.V. All rights reserved.
    The International journal on drug policy 07/2015; DOI:10.1016/j.drugpo.2015.07.002 · 2.54 Impact Factor
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    • "Globally, 10 million PWID are estimated to be infected [2]; however, the majority of these patients remain untreated, with uptake rates for interferon-containing regimens of less than 10 percent and high rates of treatment discontinuation [5–7,12,13]. While lack of diagnosis and access to care are significant factors contributing to this low rate of treatment, the real and perceived side effects of interferon-based treatment also play a role [21] [22]. PWID may be dissuaded from seeking treatment based on information about the difficulties of interferon therapy obtained from peer networks [23]. "
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    ABSTRACT: HCV-infected patients with a history of injection drug use have low rates of initiation and completion of interferon-based therapies. This study evaluated efficacy, safety, and pharmacokinetics of a 12-week all-oral regimen of ombitasvir/paritaprevir/ritonavir and dasabuvir +ribavirin in HCV genotype 1-infected patients on stable opioid replacement therapy. This was a phase 2, multicenter, open-label, single arm study in treatment-naïve or peginterferon/ribavirin-treatment experienced HCV genotype 1-infected patients on methadone or buprenorphine +/-naloxone. Patients received 12 weeks of co-formulated ombitasvir/paritaprevir/ritonavir(25mg/150mg/100mg once daily) and dasabuvir(250mg twice daily) +weight-based ribavirin. The primary efficacy endpoint was sustained virologic response 12 weeks post-treatment. Thirty-eight non-cirrhotic patients on chronic methadone(n=19) or buprenorphine(n=19) were enrolled. A total of 37 patients(97.4%) had a sustained virologic response 12 weeks post-treatment. No patient had a viral breakthrough or relapse. One patient discontinued due to serious adverse events unrelated to study drug (cerebrovascular accident and sarcoma). The most frequent adverse events were nausea, fatigue, and headache. Eight patients had on-treatment hemoglobin concentrations <10g/dL. Pharmacokinetic analyses indicated no clinically meaningful impact of methadone or buprenorphine on ombitasvir, paritaprevir, ritonavir, dasabuvir, or dasabuvir M1 metabolite exposures. No dose adjustments of methadone or buprenorphine were required CONCLUSIONS: The interferon-free regimen of ombitasvir/paritaprevir/r and dasabuvir +ribavirin for 12 weeks was well-tolerated and achieved sustained virologic response in 97.4% of patients on opioid substitution therapy in this study. This all-oral regimen may provide an effective alternative to interferon-based therapies for HCV-infected patients with a history of injection drug use. Copyright © 2015. Published by Elsevier B.V.
    Journal of Hepatology 03/2015; 11(2). DOI:10.1016/j.jhep.2015.03.029 · 11.34 Impact Factor
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    • "Moreover, some evidence suggests that a high proportion (>80%) of patients can achieve the same results regardless of whether they take TPV twice or three times daily [12]. However it has been documented that some patients who lack effective support systems, or whose medical, behavioral or social problems complicate treatment, do not receive access to treatment [13, 14]. "
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    ABSTRACT: Hepatitis C virus (HCV) infections are a severe burden on public health worldwide, causing mortality rates triple that of the general population. Since 2011, for both therapy-naive and therapy-experienced genotype 1 patients, the first generation of direct acting antivirals (DAAs), i.e., the protease-inhibitors (PI) telaprevir and boceprevir have been added to existing dual therapies. The therapeutic effect of the resulting triple therapy is striking; however, treatment regimens are complex and commonly cause side effects. Little is known of how patients implement therapy in their daily lives, or of how they deal with these effects. This study aims to describe HCV patients' experiences with protease-inhibitor-based triple therapy and their support needs. A qualitative design was used. Patients from three outpatient clinics, with ongoing, completed or discontinued PI treatment experience were recruited using a maximum variation sampling approach. Open-ended interviews were conducted and analyzed using thematic analysis according to Braun & Clarke (Qual Res Psychol 3:77-101, 2006). Thirteen patients participated in the interviews. All described themselves as highly motivated to undergo treatment, since they saw the new therapy as a “real chance” for a cure. However, all later described the therapy period as a struggle. The constitutive theme–“Fighting an uphill battle”– describes the common existential experience of and negative consequences of coping with side effects. The processes that fostered this common experience followed three sub-themes: “encountering surprises”, “dealing with disruption” and “reaching the limits of systems”. HCV patients undergoing outpatient protease-inhibitor-based triple therapy need systematic support in symptom management. This will require specially trained professionals to advise and support them and their families, and to provide rapid responses to their needs throughout this complex course of therapy. As the generation of DAAs for all genotypes, are expected to have less severe side effects, and many HCV patients require treatment, this knowledge can improve treatment support tremendously, especially for patients who are quite difficult to treat. Furthermore, these findings are helpful to illustrate development in HCV treatment.
    BMC Infectious Diseases 09/2014; 14(1):507. DOI:10.1186/1471-2334-14-507 · 2.61 Impact Factor
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