The impact of injecting drug use status on hepatitis C-related referral and treatment

https://doi.org/10.1016/j.drugalcdep.2004.07.002Get rights and content

Abstract

More than 160,000 people are living with chronic hepatitis C virus (HCV) infection in Australia, however, rates of medical treatment are low. The aim of this study is to examine uptake and predictors of HCV-related health care services among a community-based sample of people with HCV. A self-administered questionnaire was completed by a largely non-clinical sample of 362 women and 308 men with HCV living in the state of Victoria. Analyses were performed according to injecting drug use (IDU) status: no history of injecting (non-IDUs), previous history of injecting (past-IDUs) and current (within the last 12 months) history of injecting (current IDUs). Bivariate and multivariate predictors of referral to a specialist liver clinic were also assessed. Fifty-one percent of participants were current IDUs, 33% past-IDUs and 16% non-IDUs. Fifty-two percent of women and 37% of men reported ever being referred to a specialist liver clinic and 18% of women and 20% of men reported previous HCV antiviral therapy. Although there were many factors related to an increased likelihood of referral (e.g. being female, longer time since diagnosis, longer consultation time at diagnosis, experiencing HCV-related symptoms), multivariate analysis revealed that not being a current IDU and seeing a GP specifically for HCV were the most important independent predictors of referral. For those who had been referred to a liver clinic, a history of IDU was associated with a lower chance of receiving antiviral therapy. IDU status is associated with both referral and treatment. The extension of HCV treatment services to involve GPs and drug and alcohol practitioners should be explored as models to improve access to antiviral therapy.

Introduction

Hepatitis C virus (HCV) infection progresses to chronic infection in 70–80% of cases, with an estimated 10–20% of those with chronic HCV infection developing cirrhosis over 20–40 years (Dore et al., 2002, Seeff, 2002). Although a minority of people with chronic HCV infection develop advanced liver disease, quality of life impairment is well documented at all disease stages (Chong et al., 2003, Foster et al., 1998).

Antiviral therapy for chronic HCV infection has improved considerably in recent years, with sustained virological response—equating to a probable cure—increasing from 15–20% with interferon monotherapy to 50–60% with pegylated interferon and ribavirin therapy (McHutchison and Fried, 2003). The achievement of viral eradication, as determined by absence of HCV RNA 6 months following completion of antiviral therapy, has been accompanied by both hepatic fibrosis regression (Poynard et al., 2002) and improvement in quality of life (Rasenack et al., 2003, Neary et al., 1999).

Despite these advances in antiviral therapy for chronic HCV infection, the number of people accessing treatment remains relatively small. In Australia, where an estimated 160,000 people have chronic HCV infection and 35,000 have clearly progressive liver disease with at least moderate hepatic fibrosis (Law et al., 2003), only 1500–2000 people undergo antiviral therapy per year (NCHECR, 2002). Australia provides government-funded antiviral therapy for people with chronic HCV infection however, several potential barriers exist in relation to treatment access. Histopathological evidence of some liver disease progression (at least mild hepatic fibrosis with moderate inflammation, or moderate hepatic fibrosis) is required, thus necessitating a staging liver biopsy. Antiviral therapy is provided through specialist clinics, requiring referral by general practitioners (GPs). Specialist HCV clinics uncommonly operate at the primary care level, and integration of HCV treatment and drug and alcohol services are limited. Although current injecting drug use was removed as an exclusion criterion for HCV antiviral therapy in Australia in May 2001, anecdotal evidence suggests that limited numbers of current injecting drug users (IDUs) have received treatment. Psychiatric co-morbidity is a further barrier to HCV antiviral therapy, largely due to concerns around interferon-related neuropsychiatric adverse events.

The objective of this study was to examine uptake and predictors of HCV treatment and care services among a large population-based sample of women and men with HCV infection, including differences in patterns of use between people who do not currently inject drugs and current IDUs.

Section snippets

Methods

In 2000, a questionnaire was administered to a sample of women with HCV (n = 362) living in the state of Victoria (Gifford et al., 2003). In 2002, with some minor modifications to take account of gender specific issues, the same questionnaire was administered to men with HCV (n = 308) living in Victoria. Indirect estimates place the prevalence of HCV in Victoria at approximately 63,000 (ANCHARD, 2002), meaning that a little over 1% of the total HCV infected population was sampled in this study.

Results

The survey return rate for women (75%) was higher than for men (53%). The lowest return rates occurred through the Hepatitis C Council mail out, and in hospital clinical settings where participants took surveys away with reply-paid envelopes. High return rates were obtained in IDU community and clinical settings, where participants completed and returned surveys to the research assistants on the spot.

Discussion

In a large population-based sample of women and men with HCV, considerable variance exists in terms of HCV treatment and care service utilisation. Several factors were associated with utilisation, including gender and IDU status. Current IDUs were particularly unlikely to have been referred for specialist assessment, and when referred were unlikely to have received HCV antiviral therapy. Current injecting drug use rather than IDU-related HCV acquisition appeared to be the greatest barrier to

Acknowledgements

We wish to acknowledge the assistance of the project officer for the women’s study N. Thomson, research assistant D. Lococo, research fellow S. Thompson, biostatistician Associate Professor Damien Jolley, co-investigators Gabriele Bammer, Mary O’Brien and Cathy Banwell and the associate investigators M. Beers, J. Byrne, W. Holmes and M. Kainer. We also wish to acknowledge the research fellow for the men’s study Meredith Temple-Smith, research assistants S. Rosengarten, D. Ware, M. Platt, T.

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