A framework for understanding factors that affect access and utilization of treatment for hepatitis C virus infection among HCV-mono-infected and HIV/HCV-co-infected injection drug users

Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
AIDS (Impact Factor: 5.55). 11/2005; 19 Suppl 3(Suppl 3):S179-89. DOI: 10.1097/01.aids.0000192088.72055.90
Source: PubMed


Treatment for hepatitis C virus (HCV) is rarely received by injection drug users (IDU), particularly those co-infected with HIV. We propose a framework for understanding factors that affect utilization and adherence to HCV therapy among HCV mono-infected and HIV/HCV-co-infected IDU. Provision of treatment requires calculation of risks and benefits including evaluation of a number of time-varying factors that collectively determine a gradient of treatment eligibility, advisability and acceptability, the relative importance of which may differ in co-infected and mono-infected IDU. Treatment eligibility is determined by a number of non-modifiable and modifiable contraindications, the latter of which can change over time rendering patients who were once ineligible eligible. Among those eligible, treatment need can be assessed by liver biopsy and therapy may be deferred in those with no liver disease and started in those with significant liver disease. Among those with moderate disease, further consideration of treatment advisability (medical factors that affect treatment response) and acceptability (individual, provider and environmental barriers) is needed before treatment decisions are made. These factors are dynamic and thus should be continually evaluated even among those who may not initially appear to be ready for treatment. An evaluation of this framework is needed to determine applicability and feasibility. Until then, treatment decisions should be made on an individual basis after careful consideration of these issues by provider and patient and efforts to develop novel strategies for identifying IDU who need treatment most (alternatives to liver biopsy) and multidimensional approaches to deliver treatment for HCV while addressing other factors including HIV infection, depression and drug use should be continued.

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    • "Issues with health service delivery inside prison were similar to those reported by individuals in the community [14], [16], [17], [31], [34]–[37]. Prisoners experienced difficulties including, the lack of availability of HCV treatment in some prisons, lack of continuity by clinic staff, long waiting lists, the challenge of hospital visits for specialist consultations, difficulties with clinic access, concerns with the quality of care and support inside prison, and failure to maintain confidentiality. "
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    ABSTRACT: Hepatitis C virus infection (HCV) has a significant global health burden with an estimated 2%-3% of the world's population infected, and more than 350,000 dying annually from HCV-related conditions including liver failure and liver cancer. Prisons potentially offer a relatively stable environment in which to commence treatment as they usually provide good access to health care providers, and are organised around routine and structure. Uptake of treatment of HCV, however, remains low in the community and in prisons. In this study, we explored factors affecting treatment uptake inside prisons and hypothesised that prisoners have unique issues influencing HCV treatment uptake as a consequence of their incarceration which are not experienced in other populations. We undertook a qualitative study exploring prisoners' accounts of why they refused, deferred, delayed or discontinued HCV treatment in prison. Between 2010 and 2013, 116 Australian inmates were interviewed from prisons in New South Wales, Queensland, and Western Australia. Prisoners experienced many factors similar to those which influence treatment uptake of those living with HCV infection in the community. Incarceration, however, provides different circumstances of how these factors are experienced which need to be better understood if the number of prisoners receiving treatment is to be increased. We developed a descriptive model of patient readiness and motivators for HCV treatment inside prisons and discussed how we can improve treatment uptake among prisoners. This study identified a broad and unique range of challenges to treatment of HCV in prison. Some of these are likely to be diminished by improving treatment options and improved models of health care delivery. Other barriers relate to inmate understanding of their illness and stigmatisation by other inmates and custodial staff and generally appear less amenable to change although there is potential for peer-based education to address lack of knowledge and stigma.
    PLoS ONE 02/2014; 9(2):e87564. DOI:10.1371/journal.pone.0087564 · 3.23 Impact Factor
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    • "of challenges they encountered in treating their HIV/HCVcoinfected patients' HCV. Some of these challenges have been classified in the literature under four interrelated domains: (a) the arduous nature of HCV therapy, (b) the patients' complicated medical and psychosocial profiles, (c) environmental or systemic obstacles (such as delays in referrals to liver specialists or lack of psychiatric services), and (d) provider-related barriers (such as lack of HCV knowledge; perceptions of nonadherence; Dore & Thomas, 2005; Mehta et al., 2005). The intersection of treatment-, patient-, and context-related challenges, we suggest, determined the providers' own readiness for treating HCV in patients with HIV, and supported their patient-centered practices. "
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    ABSTRACT: Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.
    Qualitative Health Research 08/2011; 22(1):54-66. DOI:10.1177/1049732311418248 · 2.19 Impact Factor
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    • "Injection-drug use continues to add to the reservoir and spread of HIV (Des Jarlais, Dehne, & Casabona, 2001) and remains hard to reach and outside of the majority of the allocation of scarce health care resources (Lieb et al., 2004). Barriers to obtaining care include motivation, lifestyle instability, drug use, mental illness, lack of health insurance, providers, and the health care environment itself (Broman, Neighbors, Delva, Torres, & Jackson, 2008; Lansky et al., 2007; Mehtaa et al., 2005). A comprehensive approach for IDUs is required that includes increased access to health care, pre and posttest HIV counseling, clinical treatment and management of addiction and community-based interventions (Estrada, 2005). "
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    ABSTRACT: About one-third of HIV-infected people in the USA have a history of injection-drug use. Injecting drugs are a primary vector for HIV transmission. Drug and alcohol use are significant contributors to sexual transmission of the virus. In South Florida, urban injection-drug users (IDUs) represent a substantial population at risk for infection. Substance use management in this group is critical. As part of a larger study of at-risk populations in South Florida, we examined mental health differences among IDUs (n=117), HIV seropositive IDUs (n=130), and HIV seronegative non-IDUs (n=169). We explored factors associated with depression and anxiety between groups, and found HIV seronegative and seropositive IDUs not receiving antiretroviral (ARV) treatment to have poorer overall mental health than both HIV seropositive participants on ARVs and non-IDU participants. Our data support systems enhancement to meet the various psychosocial and health care needs among IDUs and highlight the need for resource allocation to target community-based integrated mental health services in urban populations. In addition, our data underscore the need for primary and secondary HIV prevention interventions to address the drug-use risk behaviors among IDUs to reduce the likelihood of HIV infection and transmission in this population.
    AIDS Care 09/2009; 22(2):152-8. DOI:10.1080/09540120903039851 · 1.60 Impact Factor
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