Barriers to and Facilitators of Hepatitis C Testing, Management, and Treatment Among Current and Former Injecting Drug Users: A Qualitative Exploration

Centre for Immediate Care Services, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
AIDS patient care and STDs (Impact Factor: 3.5). 12/2010; 24(12):753-62. DOI: 10.1089/apc.2010.0142
Source: PubMed


Hepatitis C (HCV) infection is common among injecting drug users (IDUs), yet accessing of HCV care, particularly HCV treatment, is suboptimal. There has been little in-depth study of IDUs experiences of what enables or prevents them engaging at every level of HCV care, including testing, follow-up, management and treatment processes. This qualitative study aimed to explore these issues with current and former IDUs in the greater Dublin area, Ireland. From September 2007 to September 2008 in-depth interviews were conducted with 36 service-users across a range of primary and secondary care services, including: two addiction clinics, a general practice, a community drop-in center, two hepatology clinics, and an infectious diseases clinic. Interviews were analyzed using a grounded theory approach. Barriers to HCV care included perceptions of HCV infection as relatively benign, fear of investigations and treatment, and feeling well. Perceptions were shaped by the discourse about HCV and "horror stories" about the liver biopsy and treatment within their peer networks. Difficulties accessing HCV care included limited knowledge of testing sites, not being referred for specialist investigations and ineligibility for treatment. Employment, education, and addiction were priorities that competed with HCV care. Relationships with health care providers influenced engagement with care: Trust in providers, concern for the service-user, and continuity of care fostered engagement. Education on HCV infection, investigations, and treatment altered perceptions. Becoming symptomatic, responsibilities for children, and wanting to move on from drug use motivated HCV treatment. In conclusion, IDUs face multiple barriers to HCV care. A range of facilitators were identified that could inform future interventions.

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Available from: Davina Swan, Jun 01, 2014
    • "Each participating practice had an intensive period of consecutive patient recruitment; this approach was found most effective in previous research in primary care (Swan et al., 2010). The researchers instructed the doctors to recruit 10 consecutive patients who were aged 18 or over, receiving addiction treatment /care (e.g., methadone), and attending a participating general practice for general medical care.. Patients were excluded from the study if they had language difficulties (i.e., unable to speak, read and write English sufficiently well to complete study questionnaires), were acutely intoxicated, and / or were cognitively impaired (including severe mental health illness) to the extent that they were unable to provide informed consent to participate. "
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    ABSTRACT: Many individuals receiving methadone maintenance receive their treatment through their primary care provider. As many also drink alcohol excessively, there is a need to address alcohol use to improve health outcomes for these individuals. We examined problem alcohol use and its treatment among people attending primary care for methadone maintenance treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care. Data on addiction care processes were collected by (1) reviewing clinical records (n = 129) of people who attended 16 general practices for methadone maintenance treatment and (2) administering structured questionnaires to both patients (n = 106) and general practitioners (GPs) (n = 15). Clinical records indicated that 24 patients (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (58% of those screened, 11% of the full sample). Of those who had positive screening results for problem alcohol use, five received a brief intervention by a GP and none were referred to specialist treatment. Scores on the Alcohol Use Disorders Identification Test (AUDIT) revealed the prevalence of hazardous, harmful, and dependent drinking to be 25% (n = 26), 6% (n = 6), and 16% (n = 17), respectively. The intraclass correlation coefficient (ICC) for the proportion of patients with negative AUDITs was 0.038 (SE = 0.01). The ICCs for screening, brief intervention, and/or referral to treatment (SBIRT) were 0.16 (SE = 0.014), -0.06 (SE = 0.017), and 0.22 (SE = 0.026), respectively. Only 12 (11.3%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/no problem alcohol use. Regular use of primary care was evident, as 25% had visited their GP more than 12 times during the past 3 months. Comparing clinical records with patients' experience of SBIRT can shed light on the process of care. Alcohol screening in people who attend primary care for substance use treatment is not routinely conducted. Interventions that enhance the care of problem alcohol use among this high-risk group are a priority.
    No preview · Article · Apr 2015 · Journal of Dual Diagnosis
    • "These include: PWID concerns regarding discrimination and confidentiality breaches in the medical setting, often exacerbated by previous negative experiences (Aitken et al., 2002; Day et al., 2008; Khaw et al., 2007; Lally et al., 2008; Strauss et al., 2008; Swan et al., 2010; Treloar, Hopwood, & Loveday, 2002; Winter et al., 2008); fear of a positive test result and its implications (Aitken et al., 2002; Craine et al., 2004; Day et al., 2008; Khaw et al., 2007; Strauss et al., 2008); limited HCV knowledge – both among PWID and providers (Aitken et al., 2002; Craine et al., 2004; Khaw et al., 2007; Lally et al., 2008; Strauss et al., 2008; Swan et al., 2010); as well as concerns regarding the phlebotomy process, particularly among PWID with damaged and difficult to access veins (Craine et al., 2004; Day et al., 2008; Khaw et al., 2007; Strauss et al., 2008; White et al., 2008; Winter et al., 2008). Testing access issues have also been highlighted, such as: lack of opportunity due to inconvenient testing sites (Lally et al., 2008; Strauss et al., 2008; Swan et al., 2010; Winter et al., 2008); limited offers of pre and post-test counselling (Khaw et al., 2007; Swan et al., 2010), and – in regard to prisons – the need for inmates to fill in testing request forms, and face long waiting times (Khaw et al., 2007). Most published research into barriers to HCV testing has been conducted in Australia (Aitken et al., 2002; Day et al., 2008; White et al., 2008; Winter et al., 2008) and the USA (Lally et al., 2008; Strauss et al., 2008). "
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    ABSTRACT: Background: Hepatitis C virus (HCV) related morbidity and mortality will continue to rise unless HCV testing and treatment uptake increases. People who inject drugs constitute those at highest risk for HCV in the UK, yet over a third who access drug and alcohol services have never received an HCV test. Method: We conducted qualitative life history research with people who have injected drugs for over six years to explore the social conditions of long-term HCV avoidance. In order to ascertain previous HCV exposure, participants were required to have an HCV antibody test at a recruiting service. We concentrate here on analyses of participant accounts in relation to HCV testing, and specifically, barriers to uptake. Thirty-seven participants were interviewed two to three times over three months. Data were analyzed according to grounded theory principles. Results: Participants had injected an average of nine years before their first HCV test. Key themes in participant accounts included: concerns regarding the process of HCV testing, including phlebotomy practices; concerns regarding the impacts of HCV diagnosis, exacerbated by confusion regarding test results and HCV effects, and fears of concomitant HIV diagnosis; optimism that testing was unnecessary given HCV risk potentials; and institutional mistrust, often internalized as felt stigma, especially in hospital settings. Conclusions: To maximize HCV testing uptake among people who inject drugs, we emphasize the need for: testing at community-based drug services; on-site skilled and non-judgemental phlebotomists; the decoupling of HCV and HIV testing; and peer-supported testing interventions.
    No preview · Article · Mar 2014 · Drugs Education Prevention & Policy
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    • "Though there was no difference in past-year testing, both groups commonly identified access to healthcare professionals as a facilitator to testing. Previous research has noted that continuity of care with a provider has fostered regular screening and, in some cases, adherence to treatment [18]. Our results suggest that PWID are more apt to receive HCV screening when it is offered as a part of routine care, rather than when it is only available “on-demand,” thereby requiring individuals to take initiative for screening themselves. "
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    ABSTRACT: People who inject drugs (PWID) are at high risk of contracting and transmitting and hepatitis C virus (HCV). While accurate screening tests and effective treatment are increasingly available, prior research indicates that many PWID are unaware of their HCV status. We examined characteristics associated with HCV screening among 553 PWID utilizing a free, multi-site syringe exchange program (SEP) in 7 cities throughout Wisconsin. All participants completed an 88-item, computerized survey assessing past experiences with HCV testing, HCV transmission risk behaviors, and drug use patterns. A subset of 362 clients responded to a series of open-ended questions eliciting their perceptions of barriers and facilitators to screening for HCV. Transcripts of these responses were analyzed qualitatively using thematic analysis. Most respondents (88%) reported receiving a HCV test in the past, and most of these (74%) were tested during the preceding 12 months. Despite the availability of free HCV screening at the SEP, fewer than 20% of respondents had ever received a test at a syringe exchange site. Clients were more likely to receive HCV screening in the past year if they had a primary care provider, higher educational attainment, lived in a large metropolitan area, and a prior history of opioid overdose. Themes identified through qualitative analysis suggested important roles of access to medical care and prevention services, and nonjudgmental providers. Our results suggest that drug-injecting individuals who reside in non-urban settings, who have poor access to primary care, or who have less education may encounter significant barriers to routine HCV screening. Expanded access to primary health care and prevention services, especially in non-urban areas, could address an unmet need for individuals at high risk for HCV.
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