Hepatitis C models of care
Christchurch Hepatitis C Community Clinic, NZ
Canterbury District Health Board engaged researchers at NCHSR to evaluate an innovative model of hepatitis C care based in Christchurch, New Zealand.
The Hepatitis C Community Clinic provides free care to people affected by hepatitis C and offers support, preparation for treatment and ongoing support during and after treatment. The evaluation included a survey of 120 clinic clients as well as interviews with clients of the clinic, people with hepatitis C not attending the clinic, clinic care workers, and other professionals with or without an association with the clinic.
In a recent paper arising from this evaluation, the majority of survey participants felt that by attending the clinic they managed their hepatitis C better, were more confident to make lifestyle changes, and experienced a less discriminatory environment than other healthcare settings. Additionally, participants attending the clinic for more than six months reported being significantly more likely to commence hepatitis C treatment within the next five years.
Results on hepatitis C knowledge in this paper were also compared with results from another recent NCHSR paper. Participants at the Christchurch clinic demonstrated a very high knowledge of hepatitis C compared with those drawn from clients of the Sydney Medically Supervised Injecting Centre and four opiate substitution clinics also in Sydney, Australia. Although not directly comparable, the knowledge scores in the Sydney study were remarkably lower than those reported in Christchurch; for example, only 17% of the Sydney sample could identify that alcohol contributes
to complications with hepatitis C compared to 97% of the Christchurch sample.
Further papers on other aspects of the Christchurch Hepatitis C Community Clinic evaluation are in the pipeline.
Horwitz, R., Brener, L., & Treloar. C. (in press). Evaluation of an integrated care service facility for people living with hepatitis C in New Zealand. International Journal of Integrated Care.
Treloar, C., Hull, P., Dore, G., & Grebely, J. (2012). Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs. Drug and Alcohol Review. Advance online publication. http://dx.doi.org/10.1111/j.1465-3362.2012.00468.x
Integrating hepatitis C treatment
Copyright Suzanne Fraser
The hepatitis C virus epidemic is a significant public health challenge in Australia and the burden of disease is increasing. In Australia, as elsewhere in the developed world, the primary risk factor for contracting HCV is injecting drug use. With well over 200,000 Australians living with chronic hepatitis C national health policy currently targets a doubling of treatment uptake to ameliorate the looming healthcare burden of end-stage liver disease and transplantation. Although treatment has improved substantially in recent years it remains a physically and
psychologically arduous and exacting regime (lasting up to a year in duration), and rates of treatment uptake remain low.
Until recently treatment has typically been delivered via a hospital-based specialist working within a dedicated multidisciplinary team. However, low rates of uptake have led to a growing interest worldwide in the provision of care and treatment within opiate substitution treatment (OST) programs (‘methadone clinics’), where a high proportion of service users are known to be living with chronic hepatitis C. In Australia for example, of the 46,000 people currently receiving OST, it is estimated that over 21,000 are also living with chronic HCV infection,
yet less than 5% have commenced treatment.
Researchers at the National Centre in HIV Social Research (NCHSR) have been collaborating on a study led by The Kirby Institute to examine the feasibility of introducing care and treatment for hepatitis C treatment within NSW OST settings. NCHSR has been investigating the attitudes of service users and staff towards the proposed integrated treatment model. In 2011 we interviewed 76 service users and staff from four ‘pilot’ sites established across NSW; two sites also included interviews with peer support workers (trained and managed by NUAA) whose
introduction was part of the study. Evaluations of this nature are ideally suited to ‘qualitative’ methods, enabling researchers to understand the ways individuals perceive and/or experience the impact of phenomena, which in turn assists in the identification of key issues—in this instance the barriers and incentives to HCV care and treatment within OST clinics.
Overall, participants reported positive experiences regarding the provision of HCV care and treatment within OST. Service users consistently lauded the logical and appropriate co-location of treatment in settings where the high prevalence of HCV is common knowledge. They reported that having HCV care in your face—i.e. onsite—served as a welcome reminder that treatment was an available and viable option. Staff also welcomed the increased availability of tangible and effective assistance for service users, describing the introduction of HCV care as better
enabling them to meet their duty of care. Both service users and clinicians noted positive changes in the atmosphere of OST clinics as a result of the initiative, particularly in those sites providing peer support programs.
Across the four pilot sites participants identified a range of positive experiences emerging from the trial. For clinicians, the opportunity to proactively engage in the care and treatment of OST clients living with HCV was key. For clients, the introduction of HCV treatment was noteworthy as both a practical, clinical intervention and as a ‘gesture’ of care—a sense of being listened and responded to. These perceptions were significant for both groups given the historical frustrations and limitations associated with both the traditional tertiary
hospital HCV treatment pathway and OST programs.
Earlier work by NCHSR researchers (Rance, Newland, Hopwood & Treloar, 2012) described some of the shared, troubling aspects of OST culture and practice, with particular reference to the potential implications this held for the introduction of HCV care and treatment. While the initial qualitative data emerging from ETHOS (Enhancing Treatment of Hepatitis C in Opiate Substitution Settings) pilot sites suggest cause for cautious optimism they do not negate the need for sustained attention to be paid to the stigmatisation embedded in the everyday institutional
practices and culture of OST. Nonetheless, one initial and encouraging finding emerging from the ETHOS study suggests the potential for the introduction of HCV care and treatment into OST settings to challenge, and even change, problematic aspects of OST culture and care.
Rance, J., & Treloar, C. (2012). Integrating treatment: key findings from a qualitative evaluation of the Enhancing Treatment of Hepatitis C in Opiate Substitution Settings (ETHOS) study (Monograph 1/2012). Sydney: National Centre in HIV Social Research, The University of New South Wales. View publication.
Rance, J., Newland, J., Hopwood, M., & Treloar, C. (2012). The politics of place(ment): providing hepatitis C treatment within opiate substitution. Social Science & Medicine, 74(2), 245–253. http://doi.dx.org/10.1016/j.socscimed.2011.10.003
Hepatitis C and injecting drug use among Aboriginal Australians
NCHSR was awarded funding by NSW Health to evaluate the Ministry’s investment in hepatitis C care and treatment services for Aboriginal people. Aboriginal Australians experience excess levels of mortality and morbidity, and this inequity is reflected in the disproportionate burden of disease with regard to hepatitis C. The evaluation aims to survey between 100 and 200 Aboriginal people living with hepatitis C, conduct follow-up interviews with a smaller sample, and interview a range of health workers involved in both general hepatitis C services and in
Aboriginal-community-controlled health services.
In June, NCHSR researchers involved in the evaluation attended the 2nd National Indigenous Drug and Alcohol Conference (NIDAC) in Fremantle, presenting an overview of the evaluation, highlighting the impact of hepatitis C on Aboriginal communities, and publicising the relevant services available.
Results from a project conducted in partnership between NCHSR and the Aboriginal Health and Medical Research Council (AHMRC) on injecting drug use among Aboriginal people in New South Wales were also presented at NIDAC. As part of this project, Monique McEwan (Harm Minimisation Project Officer at AHMRC) undertook an internship with NHCSR, leading an analysis of data previously collected as part of the NSW Pharmacy Needle and Syringe Survey (Bryant, Wilson, Hull, & Treloar, 2010) in which data was collected from injecting drug users accessing sterile injecting
equipment from pharmacies. Results from the Pharmacy Survey showed Aboriginal people are over-represented among clients of pharmacy equipment programs.
Monique McEwan (AHMRC), Dr Dana Paquette (NCHSR) and Dr Joanne Bryant (NCHSR) undertook an analysis of the pharmacy data, specifically examining the different experiences of Aboriginal and non-Aboriginal participants. Aboriginal people who inject drugs have been identified as a population at increased risk for acquiring blood-borne viruses such as hepatitis C, but to date little information about injecting drug use and risk practices had been available. Monique presented the results of their analysis at NIDAC and distributed a fact sheet ‘Injecting drug use
among Aboriginal people in New South Wales’, reporting the findings.
Bryant, J., Wilson, H., Hull, P., & Treloar, C. (2010). Pharmacy Needle and Syringe Survey, New South Wales 2006–2008 (Monograph 2/2010). Sydney: National Centre in HIV Social Research, The University of New South Wales.
McEwan, M., Paquette, D., & Bryant, J. (2012). Injecting drug use among Aboriginal people in New South Wales. Sydney: National Centre in HIV Social Research, The University of New South Wales.
These and other NCHSR publications can be found at: http://nchsr.arts.unsw.edu.au/publications/
Exploring the relationship between implicit self-representation, drug use and drug treatment
Research into implicit social cognition suggests that people’s attitudes and beliefs need not be available to conscious awareness in order to have an influence on behaviour. As a consequence, assessment of implicit attitudes has become an important feature of both attitude and addiction research, and implicit attitudes have been shown to reliably correlate with substance use. Measuring implicit associations with drug use may be an important complement to self-report measures in efforts to explain inconsistencies between conscious and unconscious
behaviours, associations and motivations. This line of inquiry is based on evidence suggesting that unconscious aspects of people’s identities can predict future behaviour independent of their conscious attitudes and beliefs.
Sociological theory stresses the link between drug use and identity and the need to reconstitute this identity as separate from drug use for successful recovery to take place. Research into this area discusses the central need for people who use illicit drugs to develop a ‘non-addict’ identity as integral to the treatment process. As noted, research in implicit social cognition suggests that people’s attitudes need not be available to conscious awareness to have an influence on behaviour. Combining these two ideas, this exploratory study aimed to
assess the association between an individual’s implicit self-representation and their drug of choice on the assumption that this relationship may be pivotal in understanding drug use, drug dependency, and ultimately recovery from drug use.
Results showed that people in treatment for heroin use had stronger implicit associations between the self and heroin than people who were in treatment for alcohol use. Greater severity of heroin use was also associated with stronger implicit associations between the self and heroin. These findings demonstrate a link between heroin and implicit self-representations and may aid our understanding of drug dependency, severity of use, and recovery from drug use while also helping to predict differential treatment success. This research is also part of a larger program of
research at NCHSR on implicit social cognition and health-related outcomes for people with stigmatised illnesses.
Brener, L., von Hippel, W., & von Hippel, C. (2012) Exploring the relationship between implicit self-representation and drug use. Addiction Research and Theory, 20(2), 133–137.
National Gay Men’s HIV Health Promotion Conference 2012
The National Gay Men’s HIV Health Promotion Conference, hosted by the Australian Federation of AIDS Organisations (AFAO), was held in Sydney in May. The conference theme, ‘Rapid Change, Growing Promise’, referred to recent developments in HIV prevention science and the opportunity to drive down HIV infections in Australia. Debate about the ‘prevention revolution’, the push to dramatically reduce HIV infections in Australia, was at times spirited. Considerable concern was also expressed at reductions in the funding of the HIV response in
some states, particularly the drastic defunding of the Queensland organisation, Healthy Communities.
NCHSR researchers were active participants in conference sessions and debates. Professor John de Wit, Director of NCHSR, gave a plenary presentation about the need for evidence to plan behavioural and community interventions during the ‘prevention revolution’. Prof de Wit noted that while clinical and biomedical interventions are subjected to considerable scrutiny and high levels of evidence are generally demanded before new interventions are adopted, the evidence for behavioural and community interventions is often patchy or
weak. Other NCHSR staff spoke in a panel discussion about challenges and opportunities in the prevention revolution.
Professor Peter Aggleton reflected on the experience of conducting HIV prevention overseas and noted that the prevention revolution in Australia would need a strong political strategy to educate policymakers about risks, such as the increase in HIV notifications that would follow a successful increase in the frequency of HIV testing.
Dr Limin Mao discussed the available data about HIV treatment uptake in Australia, noting that a substantial minority of HIV-positive gay men are not currently on treatment. Levels of HIV testing among gay men were discussed by Dr Martin Holt, suggesting that there are substantial opportunities (and challenges) in increasing HIV testing frequency. Dean Murphy reviewed the case for HIV pre-exposure prophylaxis (PrEP) for gay men at high risk of HIV, and discussed hurdles in making PrEP available in Australia.
For details about conference debates and resolutions, please see the AFAO blog ... http://afaotalks.blogspot.com.au/search/label/AFAO%20Conference%202012