The Contribution Of Injection Drug Use To Hepatitis C Virus Transmission Globally Regionally And At Country Level: A Modelling Study
- Population Health Sciences, University of Bristol, Bristol, UKNational Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK
- AffiliationsNational Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW, AustraliaCentre for Youth Substance Abuse Research, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, AustraliaInstitute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USAThe Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
- AffiliationsPopulation Health Sciences, University of Bristol, Bristol, UKDivision of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA
- Population Health Sciences, University of Bristol, Bristol, UKNational Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK
- Population Health Sciences, University of Bristol, Bristol, UKNational Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UKNational Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Population Health Sciences, University of Bristol, Bristol, UKNational Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, UK
Barriers To Accessing Hepatitis C Treatment
In spite of recent improved treatment outcomes for hepatitis C patients, available data show treatment uptake continues to be very low among injecting drug users. The literature highlights a number of possible reasons for this. Service providers cite concerns around adherence, risk of exacerbation of psychiatric disorders and the potential for reinfection after treatment as reasons for not assessing or treating hepatitis C in injecting drug users . On the part of patients, the lack of access of people who inject drugs to testing still constitutes a key-barrier to entering a care pathway. In addition, poor knowledge about hepatitis C and treatment availability, the absence of noticeable symptoms and the perceived side-effects of treatment are named as barriers for accessing hepatitis C care. Finally, until recently, current drug injecting was an exclusion criterion for receiving government-funded hepatitis C antiviral treatment in a number of European countries. This obstacle, however, is now being removed, with most clinical guidelines revised to allow for the treatment of hepatitis C in injecting drug users.
How Will My Provider Monitor Me During The Treatment
Your provider will meet with you during treatment to review how well you are tolerating treatment and review laboratory results. Laboratory tests help keep tabs on your health, track the viral load, and determine your response to treatment. You will be given specific dates to go get your blood tested at the lab during and after the treatment.
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Data Synthesis And Statistical Analysis
The present meta-analysis was conducted by generating pooled odds ratios and the 95% confidence intervals on recognizing factors associated with HCV testing among PWID. We computed the OR applying a 2*2 table, and we considered OR< 1 as a positive association between HCV testing and the target variable. An OR > 1 suggests a protective relationship between variables and vice versa. To evaluate the lack of correlation between studies, we applied Q test with a P value < 0.05 and I2 statistics with a cutoff of 50%. We assessed 95% confidence intervals for I2 where we considered negative values as zero. We applied the random-effects model to calculate pooled estimation, considering the different sampling methods of the studies. To identify any publication bias, we used Beggs and Eggers publication bias approach both in graphical and statistical manners . P-values of less than 0.05 were considered significant. We demonstrated the association between social and demographical determinants by an OR and 95% CI, and showed the results in forest plots. For data analysis, we conducted the meta and metabias commands in STATA version 13.0 (STATA Corporation, College Station, TX.
Hepatitis C Treatment As Prevention
Recent advances in hepatitis C treatment approaches, including the use of direct-acting antiviral agents and interferon-free treatment regimes show much promise , including the potential for treating hepatitis C among injecting drug users. In this area, modelling studies suggest that hepatitis C treatment could play an important role in preventing spread of the virus. A study by indicated that a 13% reduction in hepatitis C prevalence might be achieved over 10 years as a result of treating 10 infections per year per 1 000 injecting drug users in injecting drug use populations with 40% prevalence.
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A Changing Landscape: Injection Drug Use On The Rise
An estimated 1% of Canada’s population have ever injected drugsFootnote 10 and about 0.3% were using injection drugs in 2014Footnote 11. PHAC estimated that people who inject drugs made up almost half of those who ever had a hepatitis C infection in 2017Footnote 4. Based on data from 2000 to 2016, PWID make up between 60% and 85% of all new HCV infections in CanadaFootnote 7Footnote 8Footnote 9. The sharing of needles, syringes and other injection equipment appears to be the primary driver of HCV transmission in Canada todayFootnote 7Footnote 8Footnote 9. A modelling study estimated that the PWID population in Canada increased by 32% between 2011 and 2016Footnote 11.
Injection drug use, social determinants of health and key populations
Injection drug use is associated with a history of trauma and family instabilityFootnote 12Footnote 13, transactional sexFootnote 12Footnote 13, food insecurityFootnote 14Footnote 15, incarcerationFootnote 12Footnote 16, insecure housingFootnote 12Footnote 17Footnote 18Footnote 19Footnote 20Footnote 21Footnote 22Footnote 23, low incomeFootnote 12Footnote 17Footnote 20Footnote 24, lower levels of educationFootnote 12, systemic discriminationFootnote 12Footnote 24 and unemploymentFootnote 21Footnote 23Footnote 25.
Understanding evolving behaviours related to HCV acquisition is essential to understanding the evolving hepatitis C epidemic among PWID.
Injection drug use equipment sharing practices are changing
Approach To Treating Drug Users
Patients with a history of substance dependence have a high prevalence of past losses and traumas. They experience stigmatization because of their substance use and often internalize the stigma. In addition, many IDUs have had negative experiences with the health care system and harbor suspicion and mistrust towards medical providers, which present challenges to developing trusting clinical relationships. Physicians can gain trust and establish good clinical relationships with IDUs by demonstrating characteristics that challenge these assumptions. Exhibiting caring and empathy, maintaining consistency, and being reliable are key features of successful patient-provider relationships. Explicitly acknowledging and reinforcing any positive change the patient is able to make, even minor progress, provides an opportunity to strengthen the patientâs sense of self-efficacy and commitment to improved health. Assessing barriers and working together with patients to generate strategies to overcome them can strengthen the clinical relationship, contribute to improved functioning, and strengthen adherence to medical care.
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What Are The Other Health Challenges For People With Hepatitis Who Inject Drugs
People with hepatitis who inject drugs often have several other health conditions at the same time, including mental illness and HIV/AIDS, thus requiring care from multiple health care providers. This is sometimes referred to as co-occurring disorders. Substance use disorder treatment is critical for PWID, as it can reduce risky behaviors that increase the chance of transmitting hepatitis. Research has shown that patients with hepatitis receiving medication-assisted treatment for their opioid addiction can be safely treated with antiviral medications.5
To enhance HCV care, NIDA is examining coordinated care models that utilize case managers to integrate HCV specialty care with primary care, substance use disorder treatment, and mental health services so that these patients get treatment regimens that address all of their health care needs. The Health Resources and Services Administrations Ryan White HIV/AIDS Program developed a free, online curriculum about HIV/hepatitis C for healthcare providers and healthcare staff to increase knowledge about co-infection among people of color in the United States.
How Do I Know If I Am Infected With Viral Hepatitis
The number of new HBV and HCV infections has been declining in recent years, but the number of people living with chronic hepatitis infections is considerable, and deaths associated with untreated, chronic hepatitis infections have been on the rise. This is because most people dont know they are infected until the disease has begun to damage the liver, highlighting why screening for viral hepatitis is so important. People with a history of drug use are generally at higher risk, and should discuss their substance use with their health care provider.
Initial screening for HBV or HCV involves antibody tests, which show whether you have been exposed to the hepatitis virus, although not necessarily whether you are still infected. A positive antibody test should then be followed up with a test that measures the amount of virus in your blood. If this follow-up test is positive, then you should seek advice from a physician that specializes in viral hepatitis treatment. Because screening for hepatitis is so critical for linking people who test positive to the care they need, NIDA is studying new rapid HCV antibody tests that can be used in drug treatment settings.
The CDC recommends that people who inject drugs be tested for hepatitis B and C as part of routine medical care. To determine if you are at risk for contracting hepatitis, HHS has created an online assessment tool to help you find out.
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Strategies To Improve Treatment And Care
A number of the lessons learned in responding to the HIV epidemic can be transferred to managing the spread of hepatitis C among injecting drug users, including recognition of the importance of putting in place a set of comprehensive, coordinated and multidisciplinary responses. These need to include the provision of HCV testing, assessment, patient education on the long-term consequences of HCV-related liver disease. The enhancement of treatment uptake is important for injectors and effective treatment options need to be available and easily accessible for this population group. The co-location of hepatitis C treatment and opioid substitution treatment is likely to facilitate user access, and might also be linked with mental health care. Improving treatment adherence among injecting drug users is another area where improvements can be made and the use of case management, support services and provider education and training is likely to enhance care.
Search Strategy And Study Selection
The process of our study selection is presented in Fig. .
Fig. 1
To evaluate the quality of papers included in the meta-analysis, we applied a modified version of NOS. This was used to evaluate statistical quality, sample representativeness, sample size, and comparability between people were the domains used for the NOS when evaluating the quality of individual studies. We applied agreement beyond chance for evaluating agreement between the two authors during the quality assessment. The levels of poor, slight, fair, moderate, substantial, and almost perfect levels of agreement were showed by the values 0, 010.02, 0.0210.04, 0.0410.06, 0.0610.08, and 0.0811.00, respectively .
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Limitations And Strengths Of The Study
The study limitations include first, relying on HCV self-reports . Although not commonly implemented such limitations could be eliminated by achieving confirmation of prior HCV testing. Second, most of the included studies were cross-sectional meaning causal and temporal relationships between risk behavior and HCV testing are not possible. However, this meta-analyses may enhance the statistical inference of analyses and incresase the reliability of the evidence. Third, few studies investigated the association between risk behavior and HCV testing, emphasizing this gap in the literature. Also, since we did not interfere with the setting of independent and dependent variables, we had to report only the data that were published in the articles. A.
The strengths of our study include the number of high-quality studies reviewed, the large representative sample and the multivariate analysis which regulaed for potential confounders. These factors provided greater statistical power and strengthened the results of the reviewed studies and enhanced the chance of recognizing a true effect of exposure . Longitudinally design research aiming at chronic HCV infection detection as well as HCV treatment enrollment, are warranted in PWIDs.
How Does Drug Use Affect Symptoms And Outcomes Of A Viral Infection
Drug use can worsen the progression of HIV and its symptoms, especially in the brain. Studies show that drugs can make it easier for HIV to enter the brain and cause greater nerve cell injury and problems with thinking, learning, and memory. Drug and alcohol use can also directly damage the liver, increasing risk for chronic liver disease and cancer among those infected with HBV or HCV.
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Chronic Hcv In Baby Boomers
Figure 1
During the 30 years between 1960 and 1990, approximately 3 million persons in the United States developed chronic HCV infection and worldwide, and the prevalence of chronic HCV approaches 123 million., On average, 2% of the world’s population is infected with HCV. The highest prevalence is found in Egypt where 22% of the entire population has HCV. The majority of Egyptians acquired HCV from vaccination against schistosomiasis during this same time period.
The highest rate of HCV infection in the United States is in persons born between the years 1945 and 1965. The vast majority of these persons were between the ages of 10 and 50 years in the 1960-1990s when the risk of acquiring HCV was the greatest. The incidence of HCV in this âbaby boomerâ cohort is 3.25%. This is nearly five-fold higher than in any other age grouping and persons with HCV within this age cohort account for about 75% of all persons with HCV in the United States. In 2012, both the Center for Disease Control and the United States Public Health Task Force recommended that all persons born within this 2-decade period receive one-time testing for anti-HCV.,
What About Patients With Hepatitis C Who Also Have Hepatitis B
Hepatitis B virus can flare in patients who are co-infected with hepatitis B and hepatitis C and are taking medication for hepatitis C. This has been reported as a potential risk for patients who are taking hepatitis C treatment and have underlying hepatitis B as well. The flare usually occurs within a few weeks after the patient starts taking medication for hepatitis C. Therefore, patients who have both hepatitis B and hepatitis C should be seen by a hepatitis expertbeforestarting treatment of the hepatitis C they may need to start taking hepatitis B treatment to avoid a hepatitis B flare.
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How Is Hepatitis C Treated
Hepatitis C virus is treated with all-oral medications. These pills, calledantiviral medications, are usually taken once per day. These antiviral medications are extremely good at attacking the virus and preventing it from multiplying.
Antiviral medications were not the original treatment for hepatitis C. Before 2014, the only treatment for hepatitis C was called interferon and ribavirin, taken as weekly injections under the skin, plus pills. Interferon treatment caused many unpleasant side effects and was not usually successful. Then a new generation of medications became available. These antiviral treatments are extremely successful at curing the virus and have very minimal side effects.
Ribavirin is still sometimes prescribed to be taken along with the new antiviral medicines, but it has become more and more uncommon that ribavirin is needed at all. Ribavirin has some mild-moderate side effects. Ribavirin is a pill taken twice per day, as 2 or 3 pills in the morning plus 2 or 3 pills at night, depending on the patient’s body weight. Most patients do not need ribavirin.
What Is Hepatitis C
Hepatitis C, a viral disease that destroys liver cells, is the most common blood-borne infection in the United States. Approximately 36,000 new cases of acute hepatitis C infection occur each year in the United States, according to the Centers for Disease Control and Prevention in Atlanta. People with acute HCV infection may exhibit such symptoms as jaundice, abdominal pain, loss of appetite, nausea, and diarrhea. However, most infected people exhibit mild or no symptoms.
About 85 percent of people with acute hepatitis C develop a chronic infection. Chronic hepatitis is an insidious disease whose barely discernible symptoms can mask progressive injury to liver cells over 2 to 4 decades. An estimated 4 million Americans are infected with chronic hepatitis C, according to CDC.
Chronic hepatitis C often leads to cirrhosis of the liver and liver cancer and causes between 8,000 and 10,000 deaths a year in the United States. It is now the leading cause of liver cancer in this country and results in more liver transplants than any other disease.
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Benefit Of Treatment To Reduce Hcv Transmission
Persons cured of chronic HCV no longer transmit the virus to others. As such, successful HCV treatment benefits public health. Several health models have shown that even modest increases in successful HCV treatment among PWID can decrease prevalence and incidence . Models developed to estimate the impact of HCV testing and treatment on the burden of HCV at a country level reveal that large decreases in HCV prevalence and incidence are possible as more persons are successfully treated . Elimination of HCV among PWID will also require scaling up harm reduction services .
- Related References
Viral Hepatitisa Very Real Consequence Of Substance Use
Hepatitis is an inflammation of the liver. It can be caused by a variety of toxins , autoimmune conditions, or pathogens .1 Viral hepatitis is caused by a family of viruses labeled A, B, C, D, and E. To learn more about the route of transmission and prognosis for each virus, visit the Centers for Disease Control and Preventions Division of Viral Hepatitis. Hepatitis B and hepatitis C are the most common viral hepatitis infections transmitted through the sometimes risky behaviors of people who use drugsparticularly among people who inject drugs. An estimated 862,000 people are living with HBV chronic infections, with about 22,000 acute infections recorded in 2017. An estimated 2.4 million Americans are living with HCV based on 2013-2016 annual average, with an estimated 44,700 new cases of acute HCV in 2017. In fact, new cases of acute HCV have increased rapidly in the US since 2010, and have most often been associated with injection drug use.6 Three out of four people living with HCV are baby boomers born between 1945 and 1965.7
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