Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention

doi:10.1016/j.drugpo.2015.04.013

International Journal of Drug Policy

Volume 26, Issue 10, October 2015, Pages 970-975

https://doi.org/10.1016/j.drugpo.2015.04.013 Get rights and content

Highlights

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Study was conducted among HCV-seronegative PWID attending needle exchange programs.
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Primary care physician (PCP) visiting was examined in relation to HCV prevention.
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Approximately one third of PWID had recently visited a PCP.
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PCP visiting was associated with a nearly 50% lower risk of HCV seroconversion.

Abstract

Background

Meaningful reductions in Hepatitis C Virus (HCV) transmission rates among persons who inject drugs (PWID) require a comprehensive prevention approach, including access to harm reduction measures and to healthcare-related interventions, such as HCV screening, testing and antiviral treatment. Little is known, however, about the role of visiting a primary care physician (PCP) in relation to HCV infection risk among PWID, when integrated within a combined prevention approach. This study assessed the association between PCP visiting and HCV seroconversion among PWID attending needle exchange programs (NEP).

Methods

A prospective cohort study, HEPCO, was conducted among active PWID in Montréal (2004–2013). Interviews scheduled at 3- or 6-month intervals included completion of an interviewer-administered questionnaire, and collection of blood samples for HCV antibody testing. HCV-seronegative participants who reported NEP attendance at baseline and had at least one follow-up visit were eligible for this study. HCV incidence was calculated using the person-time method. Time-varying Cox regression modeling was conducted to evaluate the relationship between self-reported recent PCP visiting and HCV incidence.

Results

At baseline assessment, of 226 participants (80.5% male; median age: 30.6 years), 37.2% reported having recently visited a PCP. During 449.6 person-years of follow-up, 79 participants seroconverted to HCV [incidence rate: 17.6 per 100 person-years, 95% confidence interval (CI): 14.0–21.8]. Covariate-adjusted analyses indicated that visiting a PCP was associated with a lower risk of HCV infection [Adjusted Hazard Ratio: 0.54, 95% CI: 0.31–0.93]. Other independent predictors of HCV infection included unstable housing, cocaine injection and prescription opioid injection.

Conclusion

Among PWID attending NEP, visiting a PCP was associated with a lower risk of HCV infection. Yet, only a minority of participants reported PCP visiting. Efforts to intensify engagement with PCP among PWID could potentially contribute to lower HCV transmission when integrated within a combined approach to prevention.

Section snippets

Background

Injection drug use is the primary driving force behind the spread of Hepatitis C Virus (HCV), particularly in developed countries (Hajarizadeh, Grebely, & Dore, 2013). Although gradual declines in HCV transmission among persons who inject drugs (PWID) have been reported in some settings in recent years, including Vancouver, Canada (Grebely et al., 2014) and Australia (Iversen, Wand, Topp, Kaldor, & Maher, 2013), the incidence of HCV remains high [20–25 per 100 person-years (p-y)] in many parts

Study design and participants

Participants were selected from the Hepatitis Cohort (HEPCO), a cohort of PWID established in November 2004 in Montréal, to examine individual and contextual factors associated with HCV transmission. Eligibility criteria for recruitment into HEPCO included self-reported use of injection drugs in the 6-month period prior to the interview, being 18 years of age or older, living in the Greater Montréal region and providing informed consent in compliance with institutional review board regulations

Results

Two hundred and twenty-six PWID who reported NEP attendance at baseline and had at least one follow-up visit were eligible for the present analyses. At baseline assessment, the median age of participants was 30.6 years (IQR: 25.7–39.4), the majority (80.5%) male, and 20.4% reported having completed college education. Unstable housing arrangements were reported by 48.2%. Eighty-four participants (37.2%) had visited a PCP in the 6-month period preceding the baseline assessment. With the exception

Discussion

Our results indicate markedly lower HCV seroconversion rates among NEP-attending PWID in Montréal who visited a PCP compared to those who did not report doing so. Further, in multivariate analyses adjusting for known confounders, visiting a PCP remained independently associated with a nearly 50% lower risk of HCV infection. To the best of our knowledge, this is the first time that the impact of PCP visiting in relation to HCV seroconversion has been examined. This finding aligns with, and

Acknowledgements

The authors would like to acknowledge Élisabeth Deschênes, Rachel Bouchard and the other staff at the HEPCO Cohort research site. A special thank you is extended to the cohort participants, without whom this research would not be possible.

This work was supported by the Canadian Institutes of Health Research [MOP135260; MOP210232] and additional support from the Réseau SIDA et Maladies Infectieuses du Fonds de la Recherche en Santé du Québec [FRSQ5227]. AAA was supported by an MSc salary award

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Cited by (8)

Associations between housing stability and injecting frequency fluctuations: findings from a cohort of people who inject drugs in Montréal, Canada
2020, Drug and Alcohol Dependence
Citation Excerpt :
However, we were unable to assess the proportion of participants in this situation, as we did not have access to participants’ previous housing status. Nevertheless, one way to undermine PWID’s isolation while mitigating their risk would be to improve their access and engagement in care, including community-based services, long-term addiction therapies, and primary healthcare (Artenie et al., 2015; Bruneau et al., 2018). It should be noted that PWID with improving housing were more likely to be frequent injectors than those with declining housing.
The relationship between housing stability and drug injecting is complex, as both outcomes fluctuate over time. The objectives were to identify short-term trajectories of housing stability and injecting frequency among people who inject drugs (PWID) and examine how patterns of injecting frequency relate to those of housing stability.
At three-month intervals, PWID enrolled between 2011 and 2016 in the Hepatitis Cohort completed an interviewer-administered questionnaire and were tested for hepatitis C and HIV infections. At each visit, participants reported, for each of the past three months, the accommodation they lived in the longest (stable/unstable) and the number of injecting days (0–30). Group-based dual trajectory modeling was conducted to identify housing stability and injecting frequency trajectories evolving concomitantly over 12 months and estimate the probabilities of following injecting trajectories conditional upon housing trajectories.
386 participants were included (mean age 40.0, 82 % male). Three housing stability trajectories were identified: sustained (53 %), declining (20 %), and improving (27 %). Five injecting frequency trajectories were identified: sporadic (26 %), infrequent (34 %), increasing (15 %), decreasing (11 %), and frequent (13 %). PWID with improving housing were less likely to increase injecting (8 %) compared to those with sustained (17 %) or declining housing (17 %).
Improving housing was associated with a lower probability of increasing injecting compared to declining housing, while sustained housing stability was associated with a higher probability of increasing injecting compared to improving housing. Therefore, policies to improve PWID’s access to stable housing are warranted and may reduce, to some extent, drug injecting and related harms.
Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs?
2019, International Journal of Drug Policy
Citation Excerpt :
Measures of engagement with healthcare services included three binary variables (yes/no): contact with a primary care physician (PCP) in the past three months, being currently enrolled in OAT and having previous HCV treatment experience. As previously (Artenie et al., 2015), contact with a PCP was defined as having visited a PCP in a clinic or local community health center at least once in the past three months. Receipt of OAT (yes/no) was defined as receiving methadone or buprenorphine/naloxone at each visit.
Multiple barriers for accessing hepatitis C virus (HCV) treatment were identified during the interferon-based (IFN) treatment era for people who inject drugs (PWID). Whether these barriers persist since the introduction of IFN-free direct-acting antiviral (DAA) agents in Canada remains to be documented. This study examined temporal trends in HCV treatment initiation and associated factors during the transition from INF-based to all-oral DAA regimens.
The study population was drawn from a prospective cohort of PWID in Montreal, Canada. At three-month/one-year intervals between 2011 and 2017, participants with chronic HCV infection completed an interviewer-administered questionnaire on socio-demographic characteristics, drug use and health service utilisation, including HCV treatment. Time-updated Cox multivariate regression models, stratified by DAA + INF (2011-2013) and all-oral DAA (2014–2017) availability periods, were conducted to examine associations between time to HCV treatment initiation and associated barriers and facilitators.
Of 308 participants (85% male, median age 42 [IQR: 33, 50]), 80 (26%) initiated HCV treatment during 915 person-years (PY). Incidence rates increased from 1.6 /100 PY (95%CI:0.9–2.6) in 2011 to 12.7 (10.6–15.1) in 2017 (p-trend = 0.0012). In multivariate analyses, visiting a primary care physician (2011–2013: aHR = 3.63[1.21–10.9]; 2014–2017: 2.52[1.10–5.77]) and frequent injection (0.23[0.05–0.99] and 0.49[0.24–0.99]) were consistently associated with treatment initiation. Participants aged >40 (2.27[1.24–4.13]), receiving opioid agonist therapy (OAT) (2.17[1.19–3.94]), and reporting prior HCV treatment (3.00[1.75–5.15]) were more likely to initiate treatment in the all-oral DAA period.
Treatment initiation increased between 2011 and 2017, but still remains low among PWID. Primary care visiting was a key facilitator regardless of the period, while engagement in OAT and health services, indicated by prior HCV treatment, increased the likelihood of treatment initiation in the DAA era. These findings suggest that access to health services is essential but not enough to scale up treatment in this population.
Development and validation of a novel scale for measuring interpersonal factors underlying injection drug using behaviours among injecting partnerships
2017, International Journal of Drug Policy
Citation Excerpt :
Young adults who inject drugs encounter ongoing political, social, economic, and physical challenges altering their access to housing, sterile injecting equipment, health care services, and social support; resulting in differing levels of marginalization (Rhodes et al., 2003). Individually, such structural factors increase one’s risk for syringe and ancillary equipment sharing and subsequently the transmission of HIV and HCV, but there is also an additive effect (Allen et al., 2012; Artenie et al., 2015; Craine et al., 2009; Hahn, Page-Shafer, Ford, Paciorek, & Lum, 2008; Iversen, Wand, Topp, Kaldor, & Maher, 2013; Maher et al., 2006; Rhodes et al., 2003). Karney et al. make the point that coordinated behavior between two people is influenced both by the interpersonal factors unique to their connection, but also due to sources proximal (e.g., immediate physical environment) and distal (e.g., policies influencing availability of sterile injecting equipment) to the partnership (Karney et al., 2010).
People who inject drugs with sexual partners or close friends have high rates of syringe/ancillary equipment sharing and HIV and hepatitis C virus (HCV) infection. Although evidence suggests that interpersonal factors underlie these higher risk profiles, there is no quantitative measure of how interpersonal factors operate within injecting relationships. We aimed to develop and validate a quantitative scale to assess levels of injecting drug-related interpersonal factors associated with risky injecting behaviours within injecting partnerships.
We conducted qualitative interviews with 45 people who inject drugs (PWID) who reported having injecting partners to inform item development, and tested these items in a quantitative study of 140 PWID from San Francisco, USA, to assess internal reliability (Cronbach’s alpha) and validity (convergent, and discriminant validity).
With results from the qualitative interview data, we developed the Interpersonal Dynamics in Injecting Partnerships (IDIP) scale with 54 final items for 5 subscales of injecting-related interpersonal factors. Exploratory factor analysis revealed 5 factors (“trust”, “power”, “risk perception”, “intimacy”, and “cooperation”) with eigenvalues of 14.32, 6.18, 3.55, 2.46, and 2.14, explaining 57% of the variance, and indicating good internal reliability (alpha: 0.92–0.68). Strong convergent validity was observed in bivariate logistic regression models where higher levels of trust, intimacy, and cooperation within partnerships were positively associated with partners sharing needles and injecting equipment, whereas higher levels of power and risk perception were negatively associated with partners sharing needles and injecting equipment.
These findings offer strong evidence that the IDIP scale provides a psychometrically sound measure of injecting drug-related interpersonal dynamics. This measurement tool has the potential to facilitate additional investigations into the individual and collective impact of trust, intimacy, power, cooperation, and risk perception on injection drug using behaviours and engagement in HIV and HCV testing and treatment among PWID in a variety of settings.
Opioid agonist treatment dosage and patient-perceived dosage adequacy, and risk of hepatitis C infection among people who inject drugs
2019, CMAJ
Citation Excerpt :
These included age (yr), sex (male/female), college education (yes/no), injecting duration (yr), past-month cocaine injection (yes/no), past-month unstable housing, past 3- or 6-month incarceration (depending on follow-up period), and previous HCV infection. As previously,24 unstable housing was defined as living on the street, in shelters or in apartment hotels rented on a monthly basis. Because access to opioid agonist treatment and risk of HCV infection might have changed over time, we also considered follow-up period (2004–2011 v. 2011–2017) as potentially confounding.
Opioid agonist treatment is considered important in preventing acquisition of hepatitis C virus (HCV) among people who inject drugs; however, the role of dosage in opioid agonist treatment is unclear. We investigated the joint association of prescribed dosage of opioid agonist treatment and patient-perceived dosage adequacy with risk of HCV infection among people who inject drugs.
We followed prospectively people who inject drugs at risk of acquiring HCV infection (who were RNA negative and HCV-antibody negative or positive) in Montréal, Canada (2004–2017). At 6-month, then 3-month intervals, participants were tested for HCV antibodies or RNA, and completed an interviewer-administered behavioural questionnaire, reporting the following: current exposure to opioid agonist treatment (yes/no), prescribed dosage either high (methadone ≥ 60 mg/d or buprenorphine ≥ 16 mg/d) or low, and perceived dosage adequacy (adequate/inadequate). We then assigned participants to 1 of 5 exposure categories: no opioid agonist treatment, high dosage of opioid agonist treatment perceived to be adequate, high dosage perceived to be inadequate, low dosage perceived to be adequate or low dosage perceived to be inadequate. To estimate associations between categories of opioid agonist treatment dosage and incident HCV infection, we conducted Cox regression analyses, adjusting for multiple confounding factors.
Of 513 participants (median age 35.0 yr, 77.6% male), 168 acquired HCV over 1422.6 person-years of follow-up (incidence 11.8/100 person-years, 95% confidence interval [CI] 10.1–13.7). We observed a gradient in the relative risks of HCV infection across categories of opioid agonist treatment dosage. Compared with people who inject drugs not receiving opioid agonist treatment, adjusted hazard ratios were 0.43 (95% CI 0.23–0.84) for those receiving high dosages perceived to be adequate, 0.61 (95% CI 0.25–1.50) for those receiving high dosages perceived to be inadequate, 1.22 (95% CI 0.74–2.00) for those receiving low dosages perceived to be adequate and 1.94 (95% CI 1.11–3.39) for those receiving low dosages perceived to be inadequate.
Risk of HCV infection varies considerably according to dosage of opioid agonist treatment and patient-perceived adequacy, with associations indicating both protective and harmful effects relative to no exposure to opioid agonist treatment.
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2024, Health Behavior and Policy Review
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Research paperHepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention

Highlights

Abstract

Background

Methods

Results

Conclusion

Section snippets

Background

Study design and participants

Results

Discussion

Acknowledgements

International Journal of Drug Policy

Drug and Alcohol Dependence

Drug and Alcohol Dependence

International Journal of Drug Policy

International Journal of Drug Policy

Drug and Alcohol Dependence

Peer-delivered hepatitis C testing and counselling: A means of improving the health of injecting drug users

Drug and Alcohol Review

Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: Room for improvement

Journal of Viral Hepatitis

Barriers and facilitators of hepatitis C screening among people who inject drugs: A multi-city, mixed-methods study

Harm Reduction Journal

The rising prevalence of prescription opioid injection and its association with hepatitis C incidence among street-drug users

Addiction

Sustained drug use changes after hepatitis C screening and counseling among recently infected persons who inject drugs: A longitudinal study

Clinical Infectious Diseases

Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: Summary guidance from CDC and the U.S. Department of Health and Human Services

Morbidity and Mortality Weekly Report

Regression models and life tables

Journal of the Royal Statistical Society Series B (Methodological)

Effect of primary medical care on addiction and medical severity in substance abuse treatment programs

Journal of General Internal Medicine

Declining incidence of hepatitis C virus infection among people who inject drugs in a Canadian setting, 1996–2012

PLOS ONE

A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs

Journal of Infectious Diseases

Epidemiology and natural history of HCV infection

Nature Reviews Gastroenterology & Hepatology

Under the watchful eye of ‘a benevolent dictator’ – General practitioner and patient experiences of hepatitis C treatment initiation and shared-care in general practice

Australian Family Physician

Hepatitis C for primary care physicians

Journal of the American Board of Family Medicine

Research paper
Hepatitis C Virus seroconversion among persons who inject drugs in relation to primary care physician visiting: The potential role of primary healthcare in a combined approach to Hepatitis C prevention