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

Abstract

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.

Follow-Up for Medical Care Among Drug Users With Hepatitis C

“…Similarly, in a study of IDUs on methadone maintenance with expedited referrals and care, only a few participants received evaluation and treatment (Fishbein et al, 2004). The combination of current or former injection drug use, poly drug use either with or without concurrent alcohol use, psychiatric co-morbidities, low education levels, a history of incarceration, low levels of use of primary care combined with distrust of providers (or provider distrust of and reluctance to serve IDU populations), and the complexity of evaluating individuals for HCV treatment create barriers that are difficult to surmount even under optimal conditions of provider support for, and encouragement of, treatment in an IDU population (Edlin et al, 2005;Mehta et al, 2005).…”

“…HCV is a severe illness, and once HCV is detected, follow-up care is essential. Studies have shown that the majority of IDUs are interested in receiving treatment for HCV (Stein, Maksad, & Clarke, 2001) but do not receive treatment, either because of unwillingness to follow through or because of other barriers, such as provider unwillingness to enroll this population into treatment protocols (Fishbein, Lo, Reinus, Gourevitch, & Klein, 2004;Giordano et al, 2005;Huckans, Blackwell, Harms, Indest, & Hauser, 2005;Kresina, Bruce, Cargill, & Cheever, 2005;Mehta et al, 2005;Stoove, Gifford, & Dore, 2005).…”

Psychiatric behavioral aspects of comanagement of hepatitis C virus and HIV

“…The major individual barriers to HCV treatment eligibility (low motivation, active injection drug use, alcohol use, depression) are modifiable. With appropriate treatment, coinfected persons deemed at first ineligible for HCV therapy can become eligible for therapy [30,31].…”

Residential Transience and HIV Risk Behaviors Among Injection Drug Users

“…Longitudinal studies cite transience as a primary reason for loss-to-follow among drug using participants (Cottler, Compton, Ben Abdallah, Horne, & Claverie, 1996;Messiah, Navaline, Davis-Vogel, Tobin-Fiore, & Metzger, 2003). Social instability and uncertain living situations are frequently cited barriers to initiation and adherence to HIV and HCV therapy among injection drug users (Bouhnik et al, 2002;Mehta et al, 2005). However, this is not the case for all drug users and little is known about the differences between those who move often and those who do not.…”